Olutunu Safe Haven
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Personal Information
Some description about this section
First Name
Last Name
Age
Date of birth
Sex
– Select –
Male
Female
Tribe (This helps our counsellors be culturally sensitive)
Religion
Marital Status
Do you have children? (If yes, number of children)
Home Address
Address Line 1
City
State
Country
Select Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belau
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo (Kinshasa)
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao S.A.R., China
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo (Brazzaville)
Reunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (Dutch part)
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia/Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom (UK)
United States (US)
United States (US) Minor Outlying Islands
United States (US) Virgin Islands
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Telephone
Emergency Contact
Some description about this section
First Name
Last Name
Relationship to you
Telephone
Employment Information
Some description about this section
Are currently working? Yes/No/Sick leave
Not working because…
Full time/Part-time/Not Applicable
Reasons For Seeking Help
Some description about this section
What are your reasons for reaching out today?
How intense is your emotional distress? (Where 0 is not at all and 10 is incapacitating)
0 (not at all)
1
2
3
4
5
6
7
8
9
10 (incapacitating)
To what degree do your problems affect your ability to perform at work, school, at home, and in your relationships with others? (Where 0 is not at all and 10 is incapacitating)
0 (not at all)
1
2
3
4
5
6
7
8
9
10 (incapacitating)
When did these problems begin, and what was happening in your life at that time?
Psychiatric and Medical History
Some description about this section
Have you ever been diagnosed with any psychiatric or mental health problems? If yes, what were you diagnosed with?
Have you ever been diagnosed with any physical health problems? If yes, what were you diagnosed with?
Are you on any medication, and what for?
Please provide the name of your family doctor and their contact information
Please provide the name of your psychiatrist/therapist (if you have any) and their contact information
Counselling Goals
Some description about this section
What motivated you to come here today?
What are your goals for counselling?
Is there anything else you would like to mention?
How did you hear about us?
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