Request for SJSM Counselling Form

Request for Counselling Form

Thank you for your interest in St. John’s – St. Margaret’s Counselling Ministry. Please complete the details below to allow us to get in contact with you. All requests are kept strictly confidential. Questions with * are required. Thanks!
Name*

First NameSurname Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
What is your gender?*

FemaleMalePrefer to discuss in session
What type of counselling are you looking for?*

Individual (for myself)Couples (for myself and partner/spouse)For my child
What is your age?*
What is your relationship status?*

SingleIn a relationshipMarriedSeparatedDivorcedWidowedOther
Are you a member of SJSM?*

YesNo
Were you referred to us by someone? If so, who? If not, how did you find out about us?*
What is your preferred mode of counselling?*

In personOnline (Zoom)No preference
Have you ever been to a counsellor or other mental health professional before? Were the sessions helpful? If so, why? If not so helpful, what could have been better for you?*
What led you to consider counselling today?*

I've been feeling depressed.I feel anxious and overwhelmed.My mood is interfering with my job or school performance.I'm struggling with building or maintaining relationships.I can't find purpose or meaning in life.I am grieving.I have experienced trauma.I need to talk through a specific challenge I am facing.I want to gain more self-confidence.I want to improve myself but don't know where to start.I'm just exploring and have more questions about how counselling works.I'd rather not say.Other
What are your expectations from your counsellor? A counsellor who...

Listens more than gives advice.Helps me to explore my past.Teaches me new skills.Helps me to change my beliefs.Assigns me homework (like journaling and other reflection exercises).Guides me in setting specific goals.Proactively checks in with me.I don't know.Other
How important is your spiritual life?

Very importantImportantI'm struggling right now with my spiritual life
What are your preferences around the spiritual component of your counselling therapy?

I would prefer to keep our sessions strictly clinical.I would welcome any biblical wisdom offered.I would be open to my counsellor recommending spiritual disciplines included within homework.Other
Which of the following resources would be useful for you?

Therapy journalingSelf-reflection worksheetsGoal-habit trackingEducational reading or videosSupport groups (e.g. grief support)Other
Privacy Policy

By completing and returning this form, you consent to St. John’s – St. Margaret’s Church’s collection, use and disclosure of your personal data (and/or the personal data of any person on whose behalf you are validly acting for or authorized to provide consent) for our church activities, programs and administration purposes in accordance with St John’s – St. Margaret’s Church’s Personal Data Protection Policy. A copy of the Personal Data Protection Policy is available at our administration office.
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Request for Counselling Form