Counselling Registration FormPlease 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 info@approacgableparenting.org.ukPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastGender *MaleFemaleDate of Birth *Ethnicity *Address *Mobile *Home Phone *Email *Dropdown *MuslimAtheistHinduChristianSikhPrefer Not to SayFirst language that you SPEAK *EnglishArabicUrduOtherFirst language that you READ *EnglishArabicUrduOtherFirst language that you WRITE. *EnglishArabicUrduOtherRelationship Status? *SingleMarriedSeparatedWidowedDivorcedChoice 9GP Details *Do you have a disability? *YesNoPlease state here!Do you have any physical health issues? *YesNoPlease state here!Do you have a mental illness? *YesNoPlease state here!Do you have any learning difficulties? *YesNoPlease state here!Are you taking any medication? *YesNoPlease state here!Have you previously had therapy? *YesNoIf Yes, when did you have therapy? And what was the outcome?Are you in therapy now? *YesNoAre you currently experiencing/suffering from any of the following?Stress, anxiety, and/or depression Family ProblemsStress, anxiety, and/or depressionPlease state hereEmergency Contact Name *FirstLastMobile *Home Phone *Are you currently in paid employment? *Yes, full timeYes, part timeNoDo you receive any benefits? *YesNoIf Yes please state belowUniversal CreditUniversal credit HB included and council tax supportChild benefitChild.tax.credits and working tax creditsChild taxMaternityPlease give us a brief description of why you have decided to come to Counselling. *Where did you hear about our counselling service? (Select all that apply) *Word of mouthSocial MediaAdvertPlease tick to confirm that there will be a minimal charge to deliver this counselling session. This will be discussed further upon your initial assessment. *I give my consentSubmit