Client Information Sheet

Client Information Sheet

By completing this form, you (client) are giving permission for your information to be shared within Vanquish Therapies for the purpose of matching you with the appropriate Counsellor, for appointment scheduling, and in the event of an emergency. If you are submitting this form on behalf of another person, please provide your own contact details in the referral section below. By signing this form, you are verifying that you have obtained the client's consent to disclose their personal information to us.

Personal Information - (Please be advised that all required fields must be completed in the form. Failure to do so may result in an error. Therefore, it is crucial that you carefully review the form and provide accurate and complete information to avoid any issues. For any fields that do not apply to you, please enter "N/A.")
Full Legal Name:*

First NameLast Name
Email*
Tel:*
Age: *
Complete Current Address:*

Address & Post Code

Street Address Line 2

City/TownState / Province

Postal Code
We primarily communicate through Emails and Whatsapp.
Is it okay for us to leave you a voicemail? *
Are you currently in Therapy/Counselling anywhere else?*
Please select the service you require:*
Name of the Emergency Contact:*

First NameLast Name
Relationship to You:*
Tel:*
GP Name:*

First NameLast Name
Practice Name:*
Practice Tel:*
Are you currently on any medication? *
If yes, please mention below what is your medication and what is it prescribed for.*
Do you have any disabilities/impairments - If so, please specify:
MondayTuesdayWednesdayThursdayFriday

To avoid any delays - Please select the accurate days and times you are available to attend weekly counselling sessions in UK time, as the practice is based in the UK. Please note - If this information is not provided there can be a delay in matching you with a counsellor. Moreover, the last session is at 6pm from Monday to Thursday, and at 5pm on Friday.*

	Morning	Afternoon	Evening
Monday
Tuesday
Wednesday
Thursday
Friday (Last session is at 5pm)

How did you become aware of our services? *

Referral (Please fill out the form below. For any fields that are not applicable, please enter N/A).
Please click below to select the referral type:*
Reason for referral:*
Please provide details of any identified risk issues or substance misuse.*
Referrers Name:*
Tel:*
Organisations Name (If applicable):
Email:*

Terms & Conditions
We understand that unforeseen circumstances may arise. However, please be aware; Due to limited availability, missing more than one session or failing to book sessions for a week or more, without prior communication, may result in the release of your reserved space with your assigned Counsellor to accommodate other individuals in need of help and support.

Payment & Acknowledgement
Date*

DayMonthYear

Our consultation/assessment and admin fee is £13. This small fee helps us ensure that those embarking on their therapeutic journey are truly committed to their well-being. Please Note: This consultation/admin fee is non-refundable as it covers the processing of your consultation regardless of attendance. Additionally, our consultation slots are limited, and once you book a slot, it is reserved just for you, making it unavailable to others. We appreciate your understanding and we are here to support you every step of the way.*

Initial Consultation

£13.00

Enter coupon

Total

£0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

By submitting this form, I understand and acknowledge that if I miss more than one session or fail to book sessions for a week or more, without communication, my reserved space will be released to benefit someone else who may need it.
Thank you for completing this form and for taking the first step towards healing. We understand that starting counselling can feel daunting but please know, Vanquish Therapies is here to support you on your journey, and we are committed to providing a supportive environment for you. Please note – Vanquish Therapies and our online counselling are not a crisis or emergency service. If you need to speak to someone immediately, please contact your GP, NHS (111),or the Samaritans (116 123).
Should be Empty:

Client Information Sheet

By submitting this form, I understand and acknowledge that if I miss more than one session or fail to book sessions for a week or more, without communication, my reserved space will be released to benefit someone else who may need it.