Client Registration Form

Ebb & Flow Counselling
Gill Norval (Prof. Dip Psy C., MNCPS)

ebb.flow.counselling@gmail.com

07980 565 221
Client Registration Form
Personal Information
Full name
including preferred pronouns
Address
Telephone number
Can a message be left? text and or voicemail
Email Address
example@example.com
Date of birth

DayMonthYear
Date
Occupation
Next of kin name and number
Medical Information
Name and address of GP
Do you suffer from any physical health conditions?
Do you suffer from any mental health conditions?
Please give details, including any medications taken.
Do you have any previous experience of counselling
What brings you to counselling now (presenting issue(s)?
When did these feelings/ issue(s) begin for you? Why? How do these feelings/ issue(s) affect you and/or others close to you? (emotionally, practically, physically, psychologically, socially)
What would you like to get out of counselling?
Preferred day/time for sessions?
Please note my availability; Tuesday 9am-5pm, Wednesday 12pm-8pm, Friday 9am-5pm. Would you like in-person, walk and talk or online counselling?
How did you hear about me?
Should be Empty:

Personal Information