SESSION & PAYMENT AGREEMENT

Please ensure payment is made directly to Amira ElDeeb before or immediately after your session.

Cancellation Policy: Kindly reschedule or cancel at least 24 hours in advance. Late cancellations will be charged the full fee, except in emergencies.

Note: Fees are subject to annual review.

CONFIDENTIALITY AGREEMENT

All communication in sessions is strictly confidential. I will not disclose any information without your written consent, except where legally required (e.g., risk of harm to self or others, or disclosure of child abuse).

Your case may be discussed anonymously in professional supervision to ensure quality of care.

Public Encounters Policy: If we meet in public, I will not initiate a greeting. You may choose to acknowledge me or not.

Personal Information

Full Name

Date of Birth:

Gender

Female

Male

Nationality

Occupation

Email:

Phone (Home)

Can leave message?

Yes

Phone (Work)

Can leave message?

Yes

Mobile

Can leave message?

Yes

Emergency Contact

Name

Relationship

Phone

Partner & Children

Marital Status

Single

Married

Separated

Divorced

Widowed

Engaged

In a relationship

Re-married

Partner’s Name

Partner’s Occupation

Duration of Relationship

Children

Parents

Something went wrong! Try submitting form once again.

Mother – Age / Cause of death / Health / Occupation

Father – Age / Cause of death / Health / Occupation

Relationship between parents when you were growing up? Who was in charge?

Any ongoing problems between parents?

Any separations or divorce? How did this affect the family and you?

Any step-family relationships?

Notes:

Relationship with Parents

Something went wrong! Try submitting form once again.

Describe your mother’s personality when you were growing up.

How close were you with your mother? Could you discuss personal things? Physical affection?

Describe your father’s personality when you were growing up.

How close were you with your father? Could you discuss personal things? Physical affection?

If step-parents, how did you get along with them?

Notes:

Brothers and Sisters

Something went wrong! Try submitting form once again.

How many siblings and what are the age differences?

Did anyone receive special attention (favourite or scapegoat)?

How did you get along then?

How do you get along now?

What were the sleeping arrangements?

Who was the most important person to you growing up?

Notes:

Other Circumstances

Something went wrong! Try submitting form once again.

Any physical illness in the family?

Any mental or emotional difficulties?

Was religion important in your family?

Any house moves? Were they significant?

Notes:

Before Age 12

Something went wrong! Try submitting form once again.

Your birth – straightforward or difficult?

Illnesses – were you ever hospitalised?

Stress symptoms (nail biting, bedwetting, nightmares, asthma, eczema)?

What kind of school did you attend first (single-sex/mixed)?

How did you like it? Did you get on with other children?

What did you learn about sex as a child (family/school/friends)?

Any unwanted sexual experiences?

Has this affected you? Did you have counselling?

Notes:

Adolescence

Something went wrong! Try submitting form once again.

How was the transition to secondary school?

How did you get along with peers?

Were you happy with school performance?

Parents’ expectations of you?

What happened when you left school (education/work)?

Notes:

Sexual Development

Something went wrong! Try submitting form once again.

Sex education as a teenager – where/what?

Were you an early or late developer?

For females: age of first period and parents’ reaction.

For males: wet dreams – how did you/parents react?

Masturbation – when, how, feelings, fantasies?

Any same-sex experiences?

Any difficult or pleasurable sexual experiences as a teenager?

Notes:

Early Sexual Experiences

Something went wrong! Try submitting form once again.

Age at first sexual relationship.

Did it include penetrative sex?

When was first intercourse?

Further/subsequent relationships?

Who ended them?

Difficulties or pleasures in those experiences?

Previous marriages or live-in relationships?

Any children or pregnancies? Terminations/miscarriages?

Sexual health issues in past relationships?

Notes

Current Relationship

Something went wrong! Try submitting form once again.

Any separations? Affairs?

First sexual experiences with current partner?

Any problems then or after living together?

Where did you live first together? Did moves affect?

How do you get on with partner’s parents? Yours?

Impact of children on relationship?

Any fertility/pregnancy issues?

Was partner present at births?

Any emotional difficulties around birth?

Contraception issues?

Plans for future children?

Notes:

Sexual Functioning in Present Relationship

Something went wrong! Try submitting form once again.

Frequency and timing of sex.

Who initiates? How? Response?

Forms of intimacy?

Preferences (lights, positions, clothing, toys, fantasies).

Mutual stimulation?

Difficulties (erection, ejaculation, lubrication, orgasm).

Use of books/videos/toys?

Impact of menstruation/HRT?

Notes:

Desired Sexual Functioning

Something went wrong! Try submitting form once again.

If you could have any partner and any setting, what would you choose?

How do you think your partner would answer this?

Notes:

General Relationship

Something went wrong! Try submitting form once again.

What interests do you both share?

What do you enjoy separately?

Do you spend time with others together?

Do you spend time alone together?

Is there anything you can’t talk about?

Notes:

Self-Perception

Something went wrong! Try submitting form once again.

How would you describe your personality and qualities?

How do you feel about your appearance?

General health, habits (surgery, drugs, alcohol, smoking).

Stress and coping methods?

How easily do you express emotions (anger)?

What does your partner like/dislike about you?

How do you feel about being a man/woman?

How do you see yourself as a partner/parent?

What ambitions do you have?

Notes:

PHYSICAL HEALTH

Do you have any medical conditions?

Medications

Doctor’s Name & Phone

Height

Weight

Describe your eating habits

Do you exercise?

Yes

How often?

Since when?

Do you smoke?

Yes

Amount

Since when?

Do you drink alcohol?

Yes

Amount

Since when?

Do you use recreational drugs?

Yes

Type

Since when?

MENTAL & EMOTIONAL WELLBEING

Any personal or family history of mental illness or hospitalization? |

Any history of addiction (self or family)?

Have you ever struggled with eating problems?

Have you had previous therapy or counselling? When? For how long? What were the reasons?

Previous Therapist’s Name

Why are you seeking therapy now?

Would you like anyone else involved in the process?

Anything else you would like your therapist to know?

Summary & Therapy Goals

Something went wrong! Try submitting form once again.

Anything missed that would help therapist understand you?

Any questions that affected you strongly?

Anything you’d rather your partner not know?

Feelings about future of relationship?

How would you describe your sexual problem?

How would your partner describe it?

Goals and expectations of treatment (for yourself, partner)?

Therapist’s diagnosis, notes on predisposing, precipitating, maintaining factors.

Notes:

CONSENT TO RELEASE CONFIDENTIAL INFORMATION

I authorize Amira ElDeeb to share confidential information with:

Name

Relationship

Phone

Types of Information to Share

Purpose of Disclosure

This authorization is valid until:

Client Signature :

Date:

Successfully submitted.

Something went wrong! Try submitting form once again.