Please fill in this form if you wish to self-refer to the Counselling service.

We will be in contact as soon as possible.

Name and contact details

We need this information to get in touch with you.

Your name:

Phone:

You must give a contact phone number

Email Addr:

You must give a contact email address

Bold bordered fields are mandatory

About you

This information will help us understand your circumstances.

Date of Birth: ?

You must tell us your date of birth.

Gender: ?

You must tell us your gender.

Living Arngmts: ?

You must tell us about your living arrangements.

Employment: ?

You must tell us your employment status.

Ethnicity: ?

You must tell us your ethnicity.

Employed by:

Language:

Relationship:

Nationality:

Gender at birth:

Sexual Orientation:

Disability:

Referral for:

You must select a value for this field.

Delivery Mode:

Contact consent:

Phone messages:

Type of risk:

Briefly describe why you would like to see us

Notes: ?

Bold bordered fields are mandatory

How do you feel?

Below is a series of questions that help us to better understand how things are for you at the moment. If you are able, please take a little time to fill them in.

History

The following questions ask a little about your history. Please choose the appropriate response.

Do you have any issues with anger or aggression?

Are you currently seeing a counsellor or mental health professional?

Have you ever seen a counsellor or mental health professional in the past?

Do you have a serious addiction to alcohol or drugs?

Have you ever been diagnosed with a psychiatric illness?

By clicking ‘send’ you’re giving permission for the information you’re providing us with here to be captured in our electronic clinical record-keeping system and for us to send you various questionnaires that ask more about how things are for you as well as obtaining feedback from you about how your treatment is progressing and your general experience of our service. Before ticking to indicate your consent it’s important to make sure that you have read and understood exactly what you’re consenting to by participation in counselling at our service. Please Click here for a full description.

Please tick to indicate your consent

You must tick the consent box.

COUNSELLING SELF-REFERRAL FORM

How do you feel?