Chronically Marvellous Counselling Application

Chronically Marvellous Counselling Application
Please note: We are currently only accepting referrals from The London Borough of Richmond Upon Thames and The London Borough of Hounslow
Our current waiting list is approximately three months.
Personal details
Title
- Full Name

First NameLast Name
NHS Number: Type NHS Number here*
Address

Street Address

Street Address Line 2

City

Postcode
Phone Number
Please enter a Mobile PhoneFormat: 00000 000 000.
- Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDOB
- Gender
- Sexual Orientation
If other, please specify
- Gender Orientation
If other, please specify
- Ethnicity
Please specify if you are from any other ethnic background:
- Occupation
- Email
example@example.com
- Number or sessions you would prefer:
1) Would you prefer your sessions to be online or in person?

Our in person postcode is TW12 2HD.
If you are a social prescriber, please only tick the In person sessions if your client has explicitly said that they would prefer this option.
2) What is your preferred method of contact and time to be contacted?
If you are a social prescriber, please ensure that the answer from question one and two has come from the client or the referral will be rejected.
How would you prefer Chronically Marvellous to contact you?
Time of contact
Is it okay for us to leave a voicemail if we cannot reach you? *
Is it okay for us to send appointment-related information by email?
3) Please describe how your medical condition, chronic illness or disability affects you.
- Please provide details below:
4) Have you ever had counselling before?
- If yes, please provide details below:
5) Is there a particular issue you would like to discuss in counselling?
- If yes, please provide details below:
6) Have you ever experienced any of the following?
Please indicate yes or no:
Other (please specify below)
7) What are you hoping to gain the most from your sessions?
8) On a scale of 1-5, with 1 being low and 5 being high, how bad would you say your condition is affecting your mental health?
Please choose one of the following:
9) Have you ever had thoughts of suicide or self-harm?
- If yes, please provide details below:
10) Are you currently taking any medication for physical or mental health conditions?
- If yes, please provide details below:
11) GP (general practitioner) details
Please provide the name of the GP practice and address below:
12) Emergency Contact Information:
- Full Name

First NameLast Name
- Relationship
- Phone Number
Please enter a valid phone number.Format: 00000-000-000.
- Email
example@example.com
13) Eligibility:

To qualify for our counselling service, confirm that you can provide the following:
If you are a social prescriber, please ensure that the client is able to prove the following:
Please confirm that you are living in the Borough of Hounslow or Richmond Upon Thames and have a long-term disability, chronic illness, or a mental health condition.
Please confirm that you are on a means tested benefit/ low income (this will be checked).
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
14) Social prescriber details:

If you are a social prescriber filling this form out on behalf of someone else, please fill in your details below:
- Full Name

First NameLast Name
- Email
example@example.com
Thank you for taking the time to complete this form. We take your privacy seriously and will keep your personal information confidential. A member of our team will be in contact within ten days to complete your assessment. If you have any questions or concerns, please do not hesitate to contact us.

Warm regards,

Chronically Marvellous Counselling Service.
Chronically Marvellous is a Registered Charity

Charity no. 1218687
Should be Empty:

Chronically Marvellous Counselling Application

Personal details

1) Would you prefer your sessions to be online or in person?

2) What is your preferred method of contact and time to be contacted?

3) Please describe how your medical condition, chronic illness or disability affects you.

4) Have you ever had counselling before?

5) Is there a particular issue you would like to discuss in counselling?

6) Have you ever experienced any of the following?

7) What are you hoping to gain the most from your sessions?

8) On a scale of 1-5, with 1 being low and 5 being high, how bad would you say your condition is affecting your mental health?

9) Have you ever had thoughts of suicide or self-harm?

10) Are you currently taking any medication for physical or mental health conditions?

11) GP (general practitioner) details

12) Emergency Contact Information:

13) Eligibility:

14) Social prescriber details: