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.
Personal details
Title*

MissMrsMrMsMx
- 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 Phone
- Date of Birth*

DayMonthYear
DOB
- Gender*

MaleFemaleOther
- Sexual Orientation*

Straight/heterosexualAsexualBisexualGayLesbianPansexualQueerDo not know/questioningPrefer not to sayOther, please specify
If other, please specify
- Gender Orientation *

AgenderGenderqueerManWomanNon-binaryTwo-spiritDo not know/questioningPrefer not to sayOther, please specify
If other, please specify
- Ethnicity*

White BritishIrishGypsy or Irish TravellerAny other White background, please specify:Mixed/Multiple ethnic groupsWhite and AsianWhite and Black CaribbeanWhite and Black AfricanAny other Mixed/Multiple ethnic background, please specify:Asian/Asian BritishIndianPakistaniBangladeshiChineseAny other Asian background, please specify:Black/African/Caribbean/Black BritishAfricanCarribeanAny other Black/African/Caribbean background, please specify:Other ethnic group, please specify:Prefer not to say
Please specify if you are from any other ethnic background:
- Occupation*
- Email*
example@example.com
- Number or sessions you would prefer:*

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

Our in person postcode is TW12 2HD.
OnlineIn person (TW12 2HD)If you are requesting In person sessions, can you confirm whether you are able to climb a flight of stairs, as we are situated on the first floor. Please only tick this box if you can climb the stairs as we do NOT have ground floor access.
2) Please describe how you medical condition, chronic illness or disability affects you.
- Please provide details below:
3) Have you ever had counselling before?
- If yes, please provide details below:
4) Is there a particular issue you would like to discuss in counselling?
- If yes, please provide details below:
5) Have you ever experienced any of the following?
Please indicate yes or no:*

- Depression- Anxiety- Panic Attacks- Trauma- Self-Harm- Substance Abuse- Eating Disorder(s)- Other (please specify)
Other (please specify below)
6) What are you hoping to gain the most from your sessions?
7) 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:*

12345
8) Have you ever had thoughts of suicide or self-harm?
- If yes, please provide details below:
9) Are you currently taking any medication for mental health conditions?
- If yes, please provide details below:
10) GP (general practitioner) details
Please provide their name and contact details below:
11) Emergency Contact Information:
- Full Name*

First NameLast Name
- Relationship*
- Phone Number
Please enter a valid phone number.
- Email*
example@example.com
12) Eligibility:

To qualify for our counselling service, confirm that you can provide the following:
A referral from your GP, social prescriber, or a link worker
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.

I confirm, I can provide proof of residency
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. If you have any questions or concerns, please do not hesitate to contact us.

Warm regards,

Chronically Marvellous Counselling Service.
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Chronically Marvellous Counselling Application

Personal details

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

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

3) Have you ever had counselling before?

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

5) Have you ever experienced any of the following?

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

7) 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?

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

9) Are you currently taking any medication for mental health conditions?

10) GP (general practitioner) details

11) Emergency Contact Information:

12) Eligibility: