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.

Unemployed Low income Student
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City Town

Postal Code
Gender
Date Of Birth
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
What is their relationship to you?
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.
Signature please, add your signature below using your mouse.

Clear
For Office use only.Admin notes:
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

COUNSELLING INTAKE FORM