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Student profile

First name / initials only

Age

Grade

Gender

Family structure

Academic stream

Referral source

Presenting concern

Primary presenting problem (in student's or referrer's words)

Duration

Domains affected

Background and history

Prior mental health contact

Family mental health history

Key stressors / life events

Cultural and contextual factors

Protective factors and strengths

Select what applies

Additional strengths not listed

Risk screening

Self-harm / suicidal ideation

Abuse / safeguarding concern

Substance use

Aggression / harm to others

Counsellor's clinical observations

What struck you in the session? Behaviour, affect, cognition, hypotheses forming?

Case formulation

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