Individual Counselling form

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Please read this form before completing. We request this is completed 24 hours before your session, which allows us to prepare for your session however If you feel uncomfortable filling out this form – please fill out this alternative form instead.

Please read the Individual Counselling Preparation document below prior to your session.

Individual counselling form

Name(Required)

First Name Last Name

D.O.B(Required)

D.O.B

Email(Required)

Enter Email Confirm Email

Please use the drop-down to select the therapist you're booked in with.(Required)

Please use the drop-down to select the therapist you're booked in with.

Your Address(Required)

Your Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

G.P. Name(Required)

G.P. Name

G.P Address(Required)

G.P Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

G.P. Phone(Required)

G.P. Phone

Goals of therapy(Required)

Goals of therapy

Your issues. Please describe the nature of your difficulties, how long you have had them, how you think they began and how they affect your life at present.(Required)

Your issues. Please describe the nature of your difficulties, how long you have had them, how you think they began and how they affect your life at present.

In what ways do you hope that treatment such as, if appropriate, counselling or therapy could help you?

Have you ever sought help for emotional or psychological difficulties before?(Required)

Have you ever sought help for emotional or psychological difficulties before?

In what ways do you hope that treatment such as, if appropriate, counselling or therapy could help you?(Required)

In what ways do you hope that treatment such as, if appropriate, counselling or therapy could help you?

Has any other member of your family had help for psychological difficulties (please give details as far as you know them(Required)

Has any other member of your family had help for psychological difficulties (please give details as far as you know them

Trigger warning. Have you ever made a suicide attempt/suicidal thoughts or self harm?(Required)

Trigger warning. Have you ever made a suicide attempt/suicidal thoughts or self harm?

Are you on any medication at present for emotional/psychological difficulties, if so, please list these?(Required)

Are you on any medication at present for emotional/psychological difficulties, if so, please list these?

Is there any concern about your drinking or issues with non prescribed/prescribed drugs?(Required)

Is there any concern about your drinking or issues with non prescribed/prescribed drugs?

Have you ever had issues with eating?(Required)

Have you ever had issues with eating?

Are you experiencing problems in relationships?(Required)

Are you experiencing problems in relationships?

Coping: How do you cope with situations?(Required)

Coping: How do you cope with situations?

How easy do you find it to recognise your own thoughts?(Required)

How easy do you find it to recognise your own thoughts?

Mother: Please describe your relationship.(Required)

Mother: Please describe your relationship.

Father: Please describe your relationship.(Required)

Father: Please describe your relationship.

Siblings: Please describe your relationship(s)(Required)

Siblings: Please describe your relationship(s)

Were there any important changes, for example, moves or any other significant events, during childhood? Including any separations from the family or parental divorce. Please give approximate ages and details.(Required)

What was your experience of school like?(Required)

What was your experience of school like?

Signature(Required)

Signature: I confirm the information provided is accurate and I've read and agree to the terms and conditions.

This field is for validation purposes and should be left unchanged.