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This enquiry form takes around 6 minutes to complete

Data Privacy Statement

We know that lots of people are dealing with lots of difficult issues during these uncertain times.  We offer counselling face to face and currently have appointments available. For those unable to travel we have limited zoom sessions available. This form is to help us support your enquiry and help us get the right support for you.

The form collects some personal information to allow us to follow up on your enquiry and to help us match you to the right therapist.  Your data will be kept secure and only used for that purpose. It will be deleted from this electronic platform once you have been allocated to a therapist.  We do use some of the information (eg: age information and postcode) to understand our client base better but nothing in that use would compromise your privacy or identify you. Continuing with this enquiry form will be considered confirmation that you have read and understood this data privacy statement.

Let's start with some basics

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* 1. How did you hear of our services?

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* 2. Your name

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* 3. Your address and postcode

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* 4. Your date of birth

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* 5. Your phone number (mobile if possible since sometimes we text information about appointments)

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* 6. Your email address (if you have one)

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* 7. How would you like us to make contact with you

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* 8. The main issue I am looking for help with is:

  Main issue Secondary issue I dont think this applies to me Not sure
Panic Attacks
Anxiety
Social
Anxiety
Low Mood/
Depression
Relationship
issues
Anger
Self-esteem
OCD
Phobia
PTSD
Grief
Couples Counselling 

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* 9. Have you had support through counselling before?

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* 10. Are you on medication related to the issue you are seeking help for?

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* 11. Do you have any contact with psychological/psychiatric services (eg CPN, or psychiatrist) or have you had in the past?

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* 12. Sorry to ask an intrusive question but do you consider yourself to be a risk to yourself and/or others at the current time?

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* 13. Emergency Contact Details

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* 14. And now we would like to ask you about some of the options we offer

We offer two main choices in therapy.

1} Working with a qualified therapist at £40 per session or, for most conditions,

2} Working with a trainee at £15 per session for 8 sessions. Our trainees are highly skilled, studying on validated courses and receive supervision for their work with clients. They can work with mild/moderate presenting issues. It is NOT possible for trainees to work with higher risk conditions like PTSD, BPD, or for people who are at high risk of suicide. This will be subject to an assessment to determine working with a student would best support your needs.

If you feel unsure which option to choose give us a call to discuss on 01236 897544

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* 15. When working with a therapist (trainee or qualified) our preferred platform is  face to face however we still offer online therapy.  Can you tell us about your preferred platform for therapy

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* 16. Can you tell us what slots you might be available for therapy sessions bearing in mind that you will need a quiet spot for around 50 to 55 minutes. Please tick all that apply. We have no evening availability for students at the moment but we have added Sunday from 10-2pm

  Morning Afternoon Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

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* 17. Finally, we need some basic screening information to help us allocate your case.  There are 10 statements. Please read each statement and think how often you have felt that way over the last week.

  Not at all Only occasionally Sometimes Often Most or all of the time
I have felt tense anxious or nervous
I have felt I have someone to turn to for support when needed
I have felt able to cope when things go wrong
Talking to people has felt too much for me
I have felt panic or terror
I made plans to end my life
I have had difficulty getting to sleep or staying asleep
I have felt despairing or hopeless
I have felt unhappy
Unwanted images have been distressing me

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* 18. Is there anything else you think we should be aware of in relation to your enquiry for support?

0 of 18 answered
 

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