Consultation Sheet
By completing this form, you (client) are giving permission for your information to be shared within Vanquish Therapies 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:
*
Are you currently in Therapy/Counselling or Coaching anywhere else?
*
Please Select
Yes
No
If you have selected 'Yes' above - Please explain reasons for working with another Therapist/Counsellor or Coach
*
*
Monday
Tuesday
Wednesday
Thursday
Friday
How did you become aware of our services?
*
Please Select
Online (Google, Bing etc)
Social Media (Facebook, Instagram)
Referral
It's Just Project
Word of mouth
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
In the box below, kindly specify 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.
Terms & Conditions
Please note:Our consultation slots are limited; therefore, this means a payment of £35 is required to secure another consultation if you miss your consultation. We appreciate your understanding.
Payment & Acknowledgement
Date
*
-
Day
-
Month
Year
Our admin fee and consultation charge is £25. This small fee helps us ensure that those embarking on their therapeutic journey are truly committed to their well-being.Please Note: This consultation/admin fee is non-refundable as it covers the processing of your consultation regardless of attendance. Additionally, our consultation slots are limited, and once you book a slot, it is reserved just for you, making it unavailable to others. We appreciate your understanding and we are here to support you every step of the way.
*
prev
next
( X )
Initial Consultation
£
25.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Thank you for completing this form and for taking the first step towards healing. We understand that starting counselling can feel daunting but please know, Vanquish Therapies is here to support you on your journey, and we are committed to providing a supportive environment for you. Please note – Vanquish Therapies and our online counselling are 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: