Client Contact Sheet


Name:	
DOB:
Age:
Contact number and/or Email:
Gender:
Nationality:	
Address:

	
Emergency contact:
Emergency phone:
GP:	
Health issues:
	
Referred by:	
Employment status:	
Time agreed:	
Fee:	
Reason for attending:	
How did you hear about the service?	
1.My Website
2.Doctor
3.Other Counsellor
4.Friend
5.IACP
6.Leaflet in Community
7.Other


Office Use
Client Code:	
Contact date:	
Final Session Date:	
Closure Type:	Planned Closure  
Client Stopped Attending 
Client Contacted by Phone/Email to Close 
Counsellor Contacted by Phone/Email to Close 
Client Referred to Another Service