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 info@approacgableparenting.org.uk

Name *

First

Last

Gender *

Male
Female
Prefer not to say

Date of Birth *

Ethnicity *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please note that we can only provide our counselling service to UK Residents only.

Mobile *

Home Phone

Email *

Religion *

First language that you SPEAK *

First language that you READ *

First language that you WRITE *

Relationship Status *

GP Details *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Do you have a disability *

Yes
No

Please state here *

Do you have any physical health issues? *

Yes
No

Please state here *

Do you have a mental illness? *

Yes
No

Please state here *

Do you have any learning difficulties? *

Yes
No

Please state here *

Are you taking any medication? *

Yes
No

Please state here *

Have you previously had therapy? *

Yes
No

If Yes, when did you have therapy? And what was the outcome? *

Are you in therapy now? *

Yes
No

Are you currently experiencing/suffering from any of the following? Please tick all that apply *

Please state here *

Emergency Contact Details

Emergency Contact Name *

Mobile *

Home Phone *

Relationship to you *

Employment

Are you currently in paid employment? *

Yes
No

Is your employment full time or part time? *

Full time
Part time

Do you receive any benefits? *

Yes
No

If Yes please state below *

Please 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) *

if other please state below *

Please tick to give consent for Approachable Parenting Counselling service to process and keep your details for as long as required *

I consent

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. *

I consent