DTCPCOUNSELLING INTAKE FORM

COUNSELLING INTAKE FORM
Welcome to Dedicated To Change Project, we ask you for your cooperation in filling out the following form. We apologise for the amount of information required as it is necessary in helping us to select the right counsellor for you.

All information provided is kept confidential according to the BACP ethical framework.
Please selected relevant box below. Please remember proof of income will be required prior to your first counselling session.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityTown

Postal Code
Gender
Date Of Birth
Email
example@example.com
Phone Number

Area CodePhone Number
May we leave a message?
Current Marital Status
Who referred you or how did you hear about us?
Were you affected by Covid-19?
Please indicate how distressing and the impact Covid-19 is currently having on you.
What other support do you feel you have at the moment?

GP DETAILS
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityTown

Postal Code
Phone Number

Area CodePhone Number
We require your GP details to comply with good practice standards and will not contact your GP without discussing it with you first.

PRESENTING ISSUES AND GOALS
Briefly describe the situation/circumstances for which counselling is being sought
What are your goals for counselling or what are you hoping to change?
Please tell us any additional background information you feel would be helpful for your counsellor to know.

SESSIONS & PAYMENTS
If eligible you will be allocated a limited amount of free counselling sessions. We will review and together we will decide whether you require additional sessions. There will be a fee for further sessions and a sliding scale will be used in line with your income to determine your fee.
Signature please, add your signature below using your mouse.
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COUNSELLING INTAKE FORM