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  • Counselling Application Form

  • Thank you for your interest in the Centre for Better Health’s counselling service. Before starting your application, please note the following:

    • This is a self-referral form and must be completed by the individual applying for counselling.
    • We will review your application and assess whether the service can meet your needs. You may be invited to attend an assessment as part of your application.
    • If you are offered counselling, we will offer you a weekly session on a day and time that matches the availability you indicate in this application. If you are unable to accept this, we will only be able to offer you one other session, after which point your application will be closed.
    • For further information, please read our counselling service guidelines.

  • Our services are only open to London residents. If you live outside of London, you can visit our website for information about other services that may be able to help.

  • We are part of the City and Hackney Wellbeing Network, which offers holistic support to improve physical and mental health. If you're not already a member, you may like to apply to join. As a member, you can access our therapeutic groups and creative courses at no cost to you. 

  • Please note that the Centre will not offer counselling to counselling students who are seeking therapy solely to fulfil their course requirements, and cannot provide written confirmation of attendance in this circumstance.

  • Data Protection

  • The Centre for Better Health needs to collect this data about you in order to establish if we can provide you with an appropriate service. We will use the information that you provide in accordance with the Data Protection Act 2018 and our Privacy Notice.

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  • Personal Details

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  • Emergency Contact Details

    Please provide the details of a person to contact in case of emergency. This can be someone who is supporting you through another service, or a friend or family member. Please ensure that the emergency contact is someone who is often available.

  • We require all individuals applying to this service to be registered with a GP surgery. Please provide your surgery details below.

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  • Self Assessment

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  • Please be aware that you cannot access counselling at CBH whilst accessing counselling with another provider.

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  • Wellbeing and Quality of Life

    Our services aim to support improved wellbeing and quality of life. To help us better understand how well we are achieving this aim, we ask that you complete a short self-report outcome measure called the ReQoL (Recovering Quality of Life) when you apply to our service and again at the end. Your responses at the beginning also enable us to further assess your needs and are an important part of your application to the service.

  • For each of the following statements, please tick one box that best describes your thoughts, feelings and activities over the last week.

  • Personal growth

    Our services also aim to support personal growth, including self-efficacy. Please answer the additional question below, which we will ask again when you leave our service.

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  • Fees

    We operate a sliding scale for daytime appointments. All evening sessions are charged at £40.

  • Your fee will be £40. 

  • Your fee will be £30 for a daytime slot (all evening slots are charged at £40). Please upload one of the following documents to evidence your circumstances:

    • Pay slip (last 3 months)
    • P60 (most recent tax year)
    • Self-assessment tax return (most recent tax year)

    Please do not upload a bank statement. 

  • Your fee will be £20 for a daytime slot (all evening slots are charged at £40). Please upload one of the following documents to evidence your circumstances:

    • Pay slip (last 3 months)
    • P60 (most recent tax year)
    • Self-assessment tax return (most recent tax year)

    Please do not upload a bank statement. 

  • Your fee will be £15 for a daytime slot (all evening slots are charged at £40). Please upload one of the following documents to evidence your circumstances:

    • Universal Credit (low income) - proof of claim (last 3 months)
    • Housing Benefit - proof of claim (last 3 months)
    • Tax Credits - proof of claim (last 3 months)"

  • Your fee will be £15 for a daytime slot (all evening slots are charged at £40). Please upload one of the following documents to evidence your circumstances:

    • Certificate of student status
    • Admissions letter

  • Your fee will be £15 for a daytime slot (all evening slots are charged at £40). Please upload one of the following documents to evidence your circumstances:

    • State pension award letter
    • Pension credit - proof of claim

  • Your fee will be £5 for a daytime slot (all evening slots are charged at £40). Please upload one of the following documents to evidence your circumstances:

    • JSA or ESA - proof of claim (last 3 months)
    • Universal Credit (out of work/unable to work), with no deductions for take-home pay - proof of claim i.e., screen shot of your statement, showing the 'what we take off (deductions)' section (last 3 months)
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  • Availability

    Your counselling will be on the same day and at the same time each week. If your availability changes whilst you are waiting for an appointment, please contact the Centre to inform us.

  • Please mark all of your availability in the section below. The more options you give us, the quicker we will be able to allocate you to a counsellor.

    • Morning sessions are 9am, 10am, 11am, 12pm
    • Afternoon sessions are 1pm, 2pm, 3pm, 4pm
    • Evening sessions are 5pm, 6pm, 7pm (Tuesday-Thursday only)

    Please note that our concession rates only apply to morning and afternoon slots. 

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  • Diversity Monitoring

    We are committed to ensuring that the clients and volunteers we work with reflect the diversity of our community, and that barriers that prevent underrepresented groups from accessing our services are gradually identified and removed. To help us to do this, we encourage you to answer the below questions.

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