Counselling Registration Form
Please complete this form, all information provided is considered highly confidential with procedures in place protecting and respecting your privacy. Please note: When processing your form, we always use codes and not your name. Please note the counselling service is currently in its pilot phase and offering low cost therapy session at £20 per session. For further information, please contact
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First language that you SPEAK
First language that you READ
First language that you WRITE.
Relationship Status?
Do you have a disability?
Do you have any physical health issues?
Do you have a mental illness?
Do you have any learning difficulties?
Are you taking any medication?
Have you previously had therapy?
Are you in therapy now?
Are you currently experiencing/suffering from any of the following?
Emergency Contact Name
Are you currently in paid employment?
Do you receive any benefits?
Where did you hear about our counselling service? (Select all that apply)
Please tick to confirm that there will be a minimal charge to deliver this counselling session. This will be discussed further upon your initial assessment.