CityHill Church Counselling Request - Marriage/Relationship

Counselling Request - Marriage/Relationship

This request is for marriage or relationship counselling.If you would like individual counselling, please use the relevant form.It is important to note that you will 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. Details of both parties must be completed, and both parties must be willing to attend counselling sessions. Alternatively, a request for individual counselling should be submitted.
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.
Name of spouse/partner*

First NameLast Name
Email of spouse/partner*
example@example.com
Phone Number of spouse/partner*
Please enter a valid phone number.Format: (000) 000-0000.
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 either of you been diagnosed by a PROFESSIONAL with any medical or psychiatric conditions?*
If YES, please specify:*
Are either of you on any medication at present?*
If YES, please specify:*
Do either of you currently struggle with an addiction of any kind?*
If you answered YES, please tell us what the 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
*

Mornings (Between 08h00 and 13h00)Afternoons (Between 13h00 and 16h00)Evenings (Between 16h00 and 19h00)
By submitting this form, you are confirming that YOUR PARTNER, who will be attending sessions with you, IS IN AGREEMENT to attend counselling.*

Agree
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