About you

Please complete this form before your first session. It gives me useful background and helps us make the best use of our time together.

Please let me know if you’d rather we through it in session.

self referral form

First name

Last name

Preferred pronouns

Date of birth

Day

Month

Year

Address

Phone

Preferred method of contact

Telehone

Text

Emergency contact name

Emergency contact number

GP surgery name

Please state any mental health diagnoses

Medication/s

Why are you looking for counselling at this moment in time?

Example: I am feeling overwhelmed at work and can't concentrate.

What feels most important for you to share at this stage?

What do you expect from counselling?

Where would you like to be at in your life by this time next year?

Have you experienced a situation in your life that you would consider to be traumatic? If yes does this have an impact on your everyday life?

Anything else you would like me to know?

I understand that counselling sessions are confidential, except in specific circumstances explained to me.

I agree that my details can be stored securely in line with GDPR.

I have read and agree to the counselling agreement / terms & conditions.