DTCPCOUNSELLING INTAKE FORM

COUNSELLING INTAKE FORM
Welcome to Dedicated to Change Project. We ask for your cooperation in filling out the following form. We apologise for the amount of information required, the more information you can provide will enable us to find the most suitable counsellor for you. All the information provided is confidential and is NOT shared with any third party. Add N/A (non-applicable) for any questions you would rather not answer.
Which offer did you qualify for? Please remember proof of circumstance will be required prior to your first counselling session.

Free counselling sessions Subsidised counselling sessions Student counselling session
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City Town

Postal Code
Gender
Date Of Birth

Month Day Year
Date
Email
example@example.com
Phone Number

Area Code Phone Number
May we leave a message?
Current Marital Status
Who referred you or how did you hear about us?
COVID-19:How has Covid-19 affected you?
Please indicate how distressing and the impact Covid-19 is currently having on you.
Do you live with anyone who is affected by Covid-19?

Yes No
What other support do you feel you have at the moment?

GP DETAILS
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City Town

Postal Code
Phone Number

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

EMERGENCY
Next of kin/ Person to alert in the event of medical emergency: (Optional)
Name

First Name Last Name
Phone Number

Area Code Phone Number
COUNSELLING
Are you currently being treated by a therapist, psychotherapist or counsellor?

Yes No
Have you previously had counselling/psychotherapy?

Yes No
If yes, describe type, length of time, how long ago?
When are you are available for your appointments?

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
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.
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COUNSELLING INTAKE FORM