Self-Referral Form
Please complete this form to self-refer for our counselling services. All information provided will be kept confidential.
1. Name
*
First Name
Last Name
2. Email
*
example@example.com
3. Phone Number
*
Please enter a valid phone number.
Format: 000-000-00000.
4. Gender Identity
*
5. Date of Birth
*
6. What is the reason for seeking therapy? What prompted you?
*
7. What type of therapy are you seeking
*
Individual
Group
8. What are your expectations for therapy/your therapist?
*
9. When was the last time you thought about suicide? Are you currently feeling suicidal (Our service is not suitable for individuals currently and actively suicidal, please seek support elsewhere)
*
10. Are you currently taking any medications? Which ones?
*
11. What GP practice are you registered with?
*
12. Have you had therapy before? How long ago?
*
13. How did you hear about us?
Over the past week, how have you felt? Tick appropriately.
Not at all (0) Only Occasionally (1) Sometimes (2) Often(3) Most or all of the time (4)
1. I have felt tense anxious or nervous
*
0
1
2
3
4
0 is , 4 is
2. I have felt I have someone to turn to for support when needed
*
0
1
2
3
4
0 is , 4 is
3. I have felt able to cope when things go wrong
*
0
1
2
3
4
0 is , 4 is
4. Talking to people has felt too much for me
*
0
1
2
3
4
0 is , 4 is
5. I have felt panic or terror
*
0
1
2
3
4
0 is , 4 is
6. I have made plans to end my life
*
0
1
2
3
4
0 is , 4 is
7. I have had difficulty getting to sleep or staying asleep
*
0
1
2
3
4
0 is , 4 is
8. I have felt despairing or hopeless
*
0
1
2
3
4
0 is , 4 is
9. I have felt unhappy
*
0
1
2
3
4
0 is , 4 is
10 Unwanted Images or memories have been distressing me
*
0
1
2
3
4
0 is , 4 is
I'd like to receive wellbeing tips from Bravecore Counselling CIC
*
Yes
No
Maybe
Initial Assessment Appointment
Appointment Policy: Please attend your booked appointment on time, an allowance of 15 minutes maximum is given, please send us an email or give us a call if you are having technical difficulties or if you need to cancel please do so 24 hours in advance. If you arrive later than 15 minutes without informing us, or you cancel less than 24 hours before the appointment session, you will need to reschedule another appointment and this will be £35.
*
Agree
Submit
Should be Empty: