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Thank you for your interest in Mind in Croydon’s Counselling Service.

Mind in Croydon’s counselling service is suitable for those with mild to moderate mental health issues and can offer up to 12 weeks of 1-2-1 counselling providing an opportunity to talk to someone who is trained to listen. Our team of counsellors use a range of modalities and are experienced in supporting clients with their individual needs.

If our service is appropriate for your needs you will be invited to attend an assessment.

Mind in Croydon’s Counselling Service is able to provide a variety of services:

• One to One Counselling

• Carer’s Counselling

• Anxiety Group

You will be asked to make a contribution towards MIND’S administrative costs.

Assessment: £10

Counselling Session’s:

Carers - Free

Unwaged contribution - £5 minimum

Waged – The suggested weekly contribution is based on your earnings (0.1% of your gross annual income e.g. £23,000 - £23 per session)

Out-of-Croydon Borough - £40 per session

The amount will be discussed and agreed with you in the assessment.

Identity

Forename

Surname

Date Of Birth

Gender

Preferred Pronoun

Demographic

Ethnicity

How would you describe your ethnic background?

Contact

How can we contact you?

Telephone

Mobile

Can we leave a message?

Address

Address 1

Address 2

Town

County

Post Code

Service User Information

Are you working at present?

Occupation

Contributions

Children

Ages

Do you have any special needs/disabilities? (please note that some of our counselling rooms are on the 2nd floor, so please indicate if stairs would cause you difficulty)

How did you hear about us

Referral Information

GP Name & Addres

Preferred time for Assessment Appointment

Preferred time for Counselling Appointments

Suitability Questions

Please state in your own words the nature of your problems and their duration:

Give a brief account of the affect these problems have on your daily life:

Have you been assessed or referred to any other service?

If yes, please give details:

What was the outcome?

Please state what medication you are taking:

Do you consider yourself to be a carer? If yes, please give details:

Who Do You Care For?

Please describe any personal issues or traumatic experiences you may have suffered in the past?

Please could you give a brief statement of what you hope to gain from counselling?

Please detail any recreational drug use

Please state current alcohol consumption