Views External

Identity

Forename

Surname

Date Of Birth

Gender

Preferred Pronoun

Demographic

Ethnicity

Contact

How can we contact you?

Home Mobile Email SMS

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:

Please detail any alcohol/drug use:

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?