Consultation and Referral Service

Finding the right therapist for you can be confusing as there are different approaches and different therapists. The one-off consultation session in itself should help you clarify which areas of your life you want to change or understand as well as help you find an approach and therapist you might work best with.

You will not be coerced in any way to have further therapy. If it is your wish the therapist conducting the consultation session will refer you to another therapist they think might suit you.

Fill out this confidential form as best you can. We will contact you within two working days to book a session with a trained and experienced counselling or psychotherapy practitioner. If certain question do not feel relevant or you would rather answer it in the session please feel free to leave it blank.

The session will last 1 hour and 20 minutes and the cost for the session is £75

THIS FORM WILL BE TREATED AS STRICTLY CONFIDENTIAL

YOUR DETAILS

Title: *

First Name: *

Last Name:

Email: *

Phone Number:

Work Telephone:

Mobile Telephone:

Can a Message be Left on Your Voicemail?: *

Yes

No

Time to be Contacted: *

Daytime

Evening

Either

Date of Birth:

Gender: *

Female

Male

Please give us a contact name and number in case of an emergency. (e.g. family member, friend or doctor): *

ABOUT YOU

Describe up to three areas in your life you are finding difficult at the moment:

Describe up to three positive areas in your life:

Describe someone or people in your life who have had/have a NEGATIVE influence on you:

Describe someone or people in your life who have had/have a POSITIVE influence on you:

Is there anything in your life that gives you meaning or direction? If there is please describe:

Do you live alone or with others? Please describe:

What are your current friendships like?:

Do you actively practise any religion? If you do please describe:

ADDITIONAL INFORMATION

Have you ever been prescribed medication for depression, anxiety, or any other mood disorder?: *

Yes

No

If yes to above please describe:

Are you currently on any medication that you think may effect therapy?: *

Yes

No

If yes to above please describe:

How much alcohol do you drink each week (if any)?:

Do you use any other mood or mind altering substances other than alcohol (e.g. cannabis, cocaine)?:

Have you had any kind of psychological therapy in the past (e.g. counselling, psychotherapy, psychiatric help)?:

Is there anything else you would like to say that may be of help in the consultation session?:

Human Test

Maths Question: 19 + 1 =

Solve this simple maths problem and enter the result. E.g. for 1+3, enter 4.

Consultation and Referral Service

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