Counselling Enquiry Form

Counselling Enquiry Form

If you need any help completing this form, please contact us at services@spaceherts.org.uk. All enquiries are treated confidentially.

This is a chargeable service

An initial consultation with our counsellors is free. Any booked counselling sessions are chargeable at the following rate:

Individual counselling with supervised trainee	£50 (for 50 mins)
Individual counselling with psychotherapist	£75 (for 50 mins)
Couples counselling	£85 (for 50 mins)

I understand that my initial consultation is free, but the fees above apply for any counselling sessions that are booked through this service (please check this box)
1. Name*

First NameLast Name
MyselfMy childA young person I care forAnother family memberOther
If you selected other, please specify below
Yes - the person requiring counselling is 16 years old or older
3. If you are completing this on behalf of someone else, please state the client's name (if for yourself, please write N/A)*
4. Relationship to the Client (if for yourself, please write N/A)*
(e.g. Mother, Father, Carer, Aunt etc.)
5. Date of birth of the client*

MonthDayYear
Date
YesNoNot applicable (client is over 18)
7. Does the client have any known diagnoses or conditions?*
8. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
9. Email*
example@example.com
10. Contact Phone Number*
10. Phone Number*

Area CodePhone Number
11. Counselling appointments take place online but occasionally we can offer face to face appointments at our Stanstead Abbotts location only (although this is not guaranteed). If you have a particular preference, please let us know.*
12. Privacy notice

Your enquiry will be securely passed to our counselling team. All information is treated confidentially. Our team aims to respond as soon as possible to arrange a brief initial call and discuss next steps.
13. Before submitting, it is important you read our Counselling Terms and Conditions
I have read and agree to the terms and conditions
Should be Empty: