Consultation Sheet
By completing this form, you (client) are giving permission for your information to be shared within VQT COACHING & THERAPY for the purpose of appointment scheduling.
Personal Information - (Please be advised that all required fields must be completed in the form. Failure to do so may result in an error. Therefore, it is crucial that you carefully review the form and provide accurate and complete information to avoid any issues. For any fields that do not apply to you, please enter "N/A.")
Your Name:
*
First Name
Last Name
Email
*
Tel:
*
We primarily communicate through Emails and WhatsApp. Do you agree to this method of communication?
*
Yes
I prefer emails but not WhatsApp (This is the only messaging/texting platform we use currently).
Is it okay for us to leave you a voicemail?
*
Please Select
Yes
No
Partner's Email
*
Partner's Contact No.
*
Are you currently in Therapy/Counselling or Coaching anywhere else?
*
Please Select
Yes
No
Please explain the reasons for working with another Therapist/Counsellor or Coach
*
Please state where you reside in the world. Please note, our Practice is based in the UK. Therefore, the Consultations and Session times are scheduled in UK time.
*
*
Monday
Tuesday
Wednesday
Thursday
Friday
How did you become aware of my services?
*
Please Select
Online (Google, Bing etc)
Social Media (Facebook, Instagram)
Referral
Word of mouth
Billboard
Please click below to select the referral type:
*
Please Select
Self-Referral
Referred Through an Organisation
Referred Through an Individual
Areas You Require Support With.
We have listed a few areas below you may require support with.
*
Communication problems
Stress
Self-Defeating Behaviour
People Pleasing
Low Confidence
Low Self-Esteem
Loneliness
Family Issues
Relationship problems
Discrimination & Racism
Fear of Intimacy
High Sensitivity
Low Mood
Personal Development
Childhood Trauma
Sexual Abuse
Abuse
Anger Management
Abortion
Affairs & betrayals
Domestic Abuse
Blended Family
Separation & Divorce
Trauma
Spirituality
Passive-aggressive behaviour
Anxiety
Depression
Please use this box to specify and describe details related to the above selected areas or mention anything else not listed above that you would like support with.
*
For example - Family & Relationship Issues: A & I have been arguing frequently over how to manage our finances. The disagreement is causing tension in our relationship and affecting our family's overall well-being.
Consultation Payment & Acknowledgement
Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Book Your 20-minute Online Consultation Slot (UK Time)
*
Please note: As each consultation space is reserved exclusively once booked, missed consultations require a new payment to book another consultation. This allows us to maintain fairness and availability for all clients. I appreciate your understanding. This consultation fee is non-refundable, as it covers the processing of your consultation regardless of attendance.
*
prev
next
( X )
Pay For Your Initial Consultation
£25.00
£
25.00
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
Thank you for completing this form and for taking the first step towards healing. I understand that starting Counselling or Coaching can feel daunting but please know, VQT COACHING & THERAPY is here to support you on your journey, and I am committed to providing a supportive environment for you. Please note – this is not a crisis or emergency service. If you need to speak to someone immediately, please contact your GP, NHS (111),or the Samaritans (116 123).
Submit
Should be Empty: