ASSESSMENT – Melisa Bassett

Your full name*

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Full address (Including postcode)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Phone Number:*

Date of Birth:*

Age:*

Marital Status:

GP name and phone number:*

Are you currently receiving treatment from a doctor or other practitioner? If yes, please give brief details.*

Are you currently taking any medication? If yes, please give details.*

From the list below check as many areas that concern you:*

What's the ONE main area you want to focus on with this package?*

Tell me some background around your struggles with this? (e.g. when did it first start? how is it impacting your life?)*

What do you most want to achieve from this RTT package? If I had a magic wand what would you most want?*

If you were no longer challenged with this issue, how would it impact your life?*

What was your relationship with your parents like? What did they teach you about being lovable? Did you have to strive / work hard or be ‘good/perfect’ to be loved by them? Did you feel emotionally validated? How did they treat/talk to you? (Please give us much info as possible)*

Has anyone else in your life made you feel badly about yourself? What does this make you believe about yourself?*

What have you said/done in your life that you feel guilt or shame about? What do you judge / criticise yourself for?*

What do you like about yourself? What are you proud of yourself for?*

What qualities gifts and talents do you have? What do other people say they love about you?*

What do you wish the 'little girl you’ had been told when she was young? If you could go back in time what would you say to her?*

Anything else you would like to get off your chest?*

Emergency Contact Name:*

Emergency contact number:*

Today's date*

Signature*

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