Individual Counselling
First name
Last name
Sex
Female
Male
Other
Date of Birth
Email
Telephone
Full address and postcode
How would you describe your ethnic origin?
Do you have any disabilities or additional needs?
How many children do you have? Please tell us about your family, age of children, diagnosis or additional need
Who do you live with?
Do you work?
GP name and Surgery
Do you consent to us contacting your GP if needed?
Yes
No
Please let us know about any holidays planned
For our planning appointments
Any days or times you CAN’T DO?
Do you smoke / drink / take drugs?
How would you describe your sleep?
Have you in the last week...
Felt like ending my life?
Yes
No
Have thought about hurting myself?
Yes
No
I have been physically violent to others?
Yes
No
Talking to others has felt too much for me?
Yes
No
I have hurt myself physically or have thoughts about this?
Yes
No
Unwanted images, memories or thoughts have distressed me?
Yes
No
I have felt humiliated or shamed by other people?
Yes
No
I am struggling to cope?
Yes
No
We need your consent
Do you consent to your DATA being held on record for purposes of you wanting to access Counselling. All of your details are kept privately unless we have concerns about your safety or that of your children. This is a legal obligation. IF we have concerns they would always be talked through with you first?
Yes
No
If appropriate, do you consent to being allocated a trainee Counsellor ? All trainee Counsellors are in their final year?
Yes
No
Please sign for consent
Send the form
Telephone
07957 425775
Email
nurturehub@icloud.com
© 2023 Nurture Hub Therapy Service
