Mr. Mrs. Miss Ms. Name: Family Name:

Age:

Mobile Phone: Home Phone:

Email Address:

When would you be available for counselling?

Early Morning (07.30 am - 09.00 am) Yes No

Morning Yes No

Afternoon Yes No

Evening Yes No

When ringing you back: Is it ok for the counsellor to contact you directly? Yes No

Or, do you prefer us to let you know the details of who we have organised for you first? Yes No

Please could you tell us briefly why you have been referred to us / why you would like counselling? This may help us in deciding which counsellor will be best for you to see, as some of them specialise in different areas.

Have you had counselling / therapy before? Yes No

If yes, please could you provide us with some further informations : (e.g. when? how long?)

How did you hear about our counselling service?

Any additional notes:

Referrals

If you are unsure that we are the right service for you, we may be able to recommend other organisations and services that are more appropriate to your needs.  Feel free to contact us for an assessment or to discuss your situation before committing yourself.