Registration Form - Ebb & Flow Counselling

Gill Norval (Prof. Dip Psy C., MNCPS Accredited) ebb.flow.counselling@gmail.com

07980565 221
Client Registration Form

Ebb & Flow Counselling
Personal Information
Full name
Address
Phone number. Can a message be left (text and voicemail)?
Email Address
example@example.com
Date of birth

MonthDayYear
Date
Occupation
Next of kin name and number
Medical Information
Name and address of GP
Do you suffer from any physical health conditions?
Do you suffer from any mental health conditions? (Please give details including any medications taken)
Counselling
Do you have any previous experience of counselling?
What brings you to counselling now (presenting issue(s)? When did these feelings/issue(s) begin for you? Why? How do these feelings/issue(s) affect you and/or others close to you? (emotionally, practically, physically, psychologically, socially)
What would you like to get out of counselling?
Preferred day/time for sessions? (Please note my availability is Tuesday 9am-5pm, Wednesday 11am-8pm). Would you like in-person, walk and talk or online counselling?
How did you hear about me
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Client Registration Form