CityHill Church Counselling Request Individual

Counselling Request - Individual

This request is for individual counselling.If you would like marriage or relationship counselling, please use the relevant form.It is important to note that you need to be able to commit to weekly one-hour sessions for a period of 6-8 weeks at the agreed time. There is an option to give a few preferable time slots. Your sessions will be on the same day at the same time each week, so please ensure you can commit to this before completing this form.
How did you hear about CityHill Counselling?
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Your Gender*
Your Age*
Relationship Status*
How long have you been in this relationship?
Have you previously been for counselling at CityHill Church or elsewhere?*
If you answered "yes" above, please confirm when and where you went for counselling and if it was successful?
Have you been diagnosed by a PROFESSIONAL with any medical or psychiatric conditions?*
If YES, please specify*
Are you on any medication at present?*
If YES, please specify*
Do you struggle currently with an addiction of any kind?*
If you answered YES, please tell us what your addiction is and list any previous treatment programmes you have participated in, including the date of admission and length of your most recent stay.
What has prompted you to request counselling, and what would you like to achieve through counselling? What steps have you taken so far?*
Please give a few options of days and times that you can make one-hour sessions. The more flexible you are in terms of the times you give us, the quicker it will be to assign you a counsellor. Please note that we do not offer sessions over the weekend.*

MondayTuesdayWednesdayThursdayFriday
Please select the options most suitable for you*

Mornings (Between 08h00 and 13h00)Afternoons (Between 13h00 and 16h00)Fridays (Between 08h00 and 13h00)
Should be Empty:

Counselling Request - Individual