Larose Counselling Services

Full Name *


Is your home in an area that is physically isolated from other homes? *
Yes No

Are there any factors affecting the access to and going into your home (e.g., lighting, broken stairs, partking, etc.)? If so, please describe. *


Are there easily accessible exits available in case of an emergency? *
Yes No

Is you home located in an area that one might consider "dangerous"? If so, what does this mean for you? *


Do you have any animals? If so, what type and how do they react to strangers? *


Are there any illnesses/conditions that might affect you or any other member's behaviours (e.g., dementia, psychosis)? If so, please describe. *


Are there any communicable diseases that have affected you or any other member of your household? If so, please describe. *


Will other people be in your home during the visit? If so, please describe how we will ensure confidentiality. *


Is there a history of drug or alcohol abuse with any current member in the home? *
Yes No

Is there a potential for violence or aggression with any current member in the home (i.e., physical, verbal, destruction of property)? *
Yes No

Are there any "triggers" that we need to know about that may result in a member becoming violent/aggressive? If so, please describe. *


Is there a history of weapon-related incidents with any current member in the home? If so, please describe. *


Is the cell phone service adequate in your area? *
Yes No

Are there any other health or safety concerns that need to be discussed at this time? *


Have there been any previous involvement with professionals coming to your home? How did it go? *


Have there been allegations against service providers? If so, please describe. *