Enquiry Form

Enquiry Form
Thank you for your interest in Help Counselling. We are a low cost counselling charity, offering short and long term counselling to adult clients. Help provides a general counselling service with an integrative approach and our counsellors are in training with professionally accredited training schools and are therefore not yet qualified. This means that we are not able to support individuals with more complex mental health needs or to offer specialist counselling.

In making your application to be considered for counselling with Help, please read all statements and fields carefully before completing the form. All sections are mandatory and must be completed in full before submission.

Counselling sessions can only take place when you are in a private and secure place where you are free from interruptions. We cannot conduct sessions with you if you are in public place or outside.

Personal Details
Name *

First Name Last Name
Date of Birth *

Day Month Year
Please note that you must be aged 18 or over
Address *

Street Address

Street Address Line 2

City

Post Code
Gender *

Male Female Prefer not to say Other
Preferred Pronouns

Contact details

Please provide us with a phone number and email address that you check regularly. If we are unable to contact you this may delay your application.
Mobile Phone Number *
Please enter a valid phone number.
Landline Phone Number

Area Code Phone Number
Please indicate whether we can leave a voicemail message. *

Yes No
Email *
example@example.com

GP Details
As with many other counselling services, we will ask you for your GP information.

Why do counselling services ask for this information?

If we become concerned about your well-being, we may need inform your GP so that they can also be involved in your care. We take this responsibility from the point of assessment. We will always aim to discuss this with you beforehand.

If you don’t know the name of your GP, please just enter the name of the surgery you are registered with.
GP Surgery / Practice Name *
Name of your GP
GP Address

Street Address

Street Address Line 2

City County

Post Code
GP Phone Number

Area Code Phone Number

Medication
Have you ever been prescribed medication for mental health difficulties? *

Yes No
Please provide details of the medication, dosage, dates including if still current and who prescribed the medication: *

Counselling
What are the main reasons you would like to have counselling? What do you hope to gain / what would you like to change? *
Have you had counselling or psychotherapy before? *

Yes No
Please provide details of previous counselling or psychotherapy including when, when, for how long, with who and type of therapy. (Please note that if you are currently having counselling elsewhere, we are not able to offer you therapy with Help Counselling at the same time.) *

Agree & Sign

Please read the following statements carefully before signing and submitting this form
Privacy Policy and Data Retention Statement for Help Counselling.

It is the aim of Help Counselling to be fully compliant with current GDPR
Legislation. GDPR replaces the previous Data Protection Act and we intend in
this policy to be transparent, with regard to the processes we have
in place. Identifiable information, if shared, will only be used in accordance
with this privacy statement. We follow guidance from the British Association
for Counselling and Psychotherapy and our insurers, Howden.

Help Counselling is the data controller and as such, is responsible for your
personal data. We are registered with the Information Commissioner’s Office
(ICO) and have appointed a Data Protection Officer (DPO). If you have
any questions about this privacy policy, including any requests to exercise
your legal rights, please contact the DPO, via the email address below:-
administrator@helpcounsellingcentre.com If we cannot resolve any matters of
interest or concern, then you can also contact the ICO directly.

As the data controller, Help Counselling will collect and process some of your
personal data, including any data you may provide through our website when
making a self referral and when you book and attend an assessment. As part
of their work, Help counsellors keep brief, factual content notes of
each session, which are anonymised and held securely for seven years. After
this period these notes will be disposed of securely.

Data processing means obtaining, recording or holding information.
Help Counselling undertakes to hold all sensitive data safely and securely.
This involves anonymising information and using passwords, codes and
encrypted documents. You have a right to see the information that Help
Counselling holds about you, you can also withdraw consent at anytime or
ask Help Counselling to delete any of the data that we hold, however there
are some details that we need to keep due to legal and professional
obligations.

It is important that you read this privacy policy carefully, together with any
other privacy, confidentiality or fair processing policy, we may provide when
we are collecting or processing personal data about you. Doing so will ensure
that you are kept informed of how and why we are using your data. This
privacy policy and data retention statement, supplements all other notices and
privacy policies and is not intended to replace or override them.
Please sign here: *

Clear
Date *

Day Month Year
Date
Should be Empty:

	Mon	Tues	Wed	Thurs	Fri
AM 9:00 - 12:00
PM 13:00 - 17:00
EVE 18:00 - 20:00

Enquiry Form

Personal Details

Contact details

GP Details

Your History

Medication

Counselling

Please give your availability for counselling sessions

Additional questions

Supplementary information

What is your ethnicity?

Agree & Sign