• 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.

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    Pick a Date
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  • HEALTH AND SOCIAL INFORMATION

  • OCCUPATIONAL, LEGAL INFORMATION

  • GP DETAILS

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  • 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)

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  • COUNSELLING

  • PRESENTING ISSUES AND GOALS

  • 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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