Counselling Request Session

Request for a Counselling Session
At Debut, we are dedicated to ensuring your well-being and personal development while you attend a course with us, and to ensure that you are prepared beyond your training.

We offer monthly counselling sessions with an open-door policy. By completing this form, you will be scheduled for a free 30 minute session. In certain circumstances, our counsellor, Kay Dodd, may recommend or request additional sessions.

Please be assured this form is strictly private and confidential!
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Please enter your Age (If you are 16 you will require parental consent)
I am 16 and I have parental consent to attend this session

YesNoOther
Please tick how you would like to have your support, please note that face to face will be best

Face to Face in WickfordPhone Call
Please tick the below to provide Kay with what areas you would like assistance with, this will provide Kay with information required to prepare for your first session:*

You are struggling with anxietyYou are struggling with depressionUnresolved issues from the pastExcessive screen timeExcessive drinking or substance abuseRelationship conflictsPersonal fears and insecuritiesLoss of motivation and will powerLack of self confidencePrioritisation of time managementNegative thoughts of yourself and harsh self critisismOther
Please tick any of the below that relate to you:*

I am currently on medication for any of the above problemsI am currently seeing a therapist for the above problemsMy doctor is aware of the above problemsNone of the above apply to meOther
What do you hope to achieve from your session/s with Kay?*

Talk to someone who is impartial about your feelings and thoughtsGain an understanding about your feelings and thoughtsLearn skills to change your feelings and thoughtsGain personal power and choice about what is going on in your lifeChange your vision for your future and understand the steps to get thereYou want to feel better and have a greater self esteem and self worthOther
What Happens Next?
- We will contact you to book your session with Kay.
- You will have a free 1-1 session with Kay.
- Kay will assess if you may need to book in further sessions or the one session may be suitable.
- All meetings are private and confidential.
- Kay has suggested, but it is not mandatory, to purchase The Manifestation Journal, which costs £4 on Amazon. it contains step by step advice as well as daily actions to help you stay on track to self discovery and more.
Cancelling Your Session

Sessions with Kay are very popular, if you are not able to attend your appointment please contact Jade on 01268 560 552, at least 24 hours prior. This will allow us to give this slot to someone else who can benefit.

Thank you for your co-operation!
Signature

By signing this form you are agreeing to having a session with Kay and you are happy for Kay to take confidential notes which are stored securely and not shared with anyone unless there is a threat to either your life or someone else's.
Signature*

Clear
Date*

DayMonthYear
Date
For Office Use Only
Jade has spoken to learner and booked a session time and date with Kay

Yes, have booked the below session with learnerNo, can't contact learnerNo, learner no longer requires the session
Date Booked: Thursday - 21.09.2023, 5.10.2023, 2.11.2023, 7.12.2023

DayMonthYear
Date
Time booked - First sessions are 45 minutes (10am to 4pm)

Hour Minutes

AM/PM Option
How has learner asked for session to be delivered?

Face to Face in WickfordPhone CallZoom Session
For Office Use Only

Book learner in for next session if Kay has advised these are 30mins
Jade has spoken to learner and booked a session time and date with Kay

Yes, have booked the below session with learnerNo, can't contact learnerNo, learner no longer requires the session
Date Booked: Thursday - 21.09.2023, 5.10.2023, 2.11.2023, 7.12.2023

DayMonthYear
Date
Time booked - Follow up sessions are 30 mins

Hour Minutes

AM/PM Option
How has learner asked for session to be delivered?

Face to Face in WickfordPhone CallZoom Session
For Office Use Only

Book learner in for next session if Kay has advised these are 30mins
Jade has spoken to learner and booked a session time and date with Kay

Yes, have booked the below session with learnerNo, can't contact learnerNo, learner no longer requires the session
Date Booked: Thursday - 21.09.2023, 5.10.2023, 2.11.2023, 7.12.2023

DayMonthYear
Date
Time booked - Follow up sessions are 30 mins

Hour Minutes

AM/PM Option
How has learner asked for session to be delivered?

Face to Face in WickfordPhone CallZoom Session
Should be Empty:

Request for a Counselling Session

For Office Use Only

For Office Use Only

For Office Use Only