Counselling Inquiry Form

I am interested in

Individual CounsellingCouple Counselling

My Name

First NameLast Name

My Partners Name

First NameLast Name

Address

Street Address

Street Address Line 2

TownCounty

Post Code

Email

example@example.com

Phone Number

Please enter a valid phone number.

Mobile Number

Please enter a valid phone number.

GP Name

Surgery

GP Phone Number

Please enter a valid phone number.

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.

I would like to access (either or both)

online/telephone counsellingface to face counselling

For online/telephone counselling

I give permission to pass on my details to the counsellor for the sole purpose of setting up online or telephone counselling.

Who referred you to Couple Counselling Fife?

Name of Referer

Confidentiality Agreement

Relationships Scotland Couple Counselling Fife provides a confidential counselling service. In order to offer our service we require to hold personal information from our clients[1] Any information you provide will be kept confidential within our organisation[2] and is the responsibility of the manager. Your personal information will not be used for any other purpose than for the provision of the counselling service.

We will not disclose this information to other individuals or external agencies without your permission, except in the following circumstances;

If there is a legal obligation.
If there are serious concerns about your own safety, or the safety of another person or child.
A disclosure is made suggesting you or your partner have benefitted from the proceeds of crime[3]
A disclosure is made relating to a serious crime.

Your counselling records will be kept securely for three years, records for Sexual Relationship Therapy will be kept for seven years. After the prescribed time your data will be disposed of securely.

We do not allow any unauthorised recordings of sessions.

Under GDPR regulations you have a right to review or change your personal data, or withdraw your consent[4]. If you wish to do so, please contact the manager, see details below, who will progress the access request within 1 month. If you are not satisfied with our response or believe we are not processing your personal data in accordance with the law you can complain to the Information Commissioner’s Office (ICO).

Mieke van der Zijpp

Manager.

[1] We hold your data in your legitimate interest.
[2] Under the Data protection Act 1998 and general Data Protection Regulation 2018
[3] Under the proceeds of crime Act 2002 and/ or relevant money laundering regulations
[4] Relationships Scotland National Policy on Client Access to Information

Confidentiality Policy Agreement*

I confirm I have read the policy on confidentiality and give my consent to proceed according to the policy.

Date

AM/PM Option

Counselling Enquiry Form