Enquiry Form
Section 1: What is the enquiry for?
Select all that apply:
*
Adult Counselling
Child/Teen Counselling
Parent Consultation
Workshop/Training Delivery
Section 2: Contact / Parent-Carer Details (to be completed for all enquiries – if adult, this is your own info; if child/teen, this is parent/carer info)
Name
*
First Name
Last Name
Relationship to child/young person (if applicable):
Contact Number
*
Email Address
*
Section 3: Client/Young Person’s Details (only complete if referral is for a child/teen)
Name
First Name
Last Name
Age:
School Year:
Gender (optional):
Preferred Pronouns:
Is the young person aware of the referral?:
Yes
No
Section 4: Appointment Preferences
Preferred Appointment Time (Select all that apply):
*
Morning
Afternoon
Evening
Preferred Type of Therapy (select all that apply):
*
In-person
Online
Telephone
Preferred appointment frequency:
Weekly
Fortnightly
Monthly
Other
Do you have a preference for sessions to be held at the same day and time each week/fortnight?
*
Yes
No
Are you seeking short-term or longer-term support
*
Short-term
Long-term
Single session
Unsure
Any accessibility needs?
Section 5: Reason for Enquiry
What are the main concerns or reasons you are seeking support at this time?
*
How long have these difficulties/concerns been present?
Have you/your child received any previous or current support (e.g. therapy, GP, mental health services)?
Are there any diagnosis, learning needs, neurodivergent traits or mental health difficulties you're aware of?
Are there any strategies, tools, or approaches that help or make things more difficult?
Section 6: Family/Context (only relevant if enquiry for child/teen/parent coaching)
Have there been any recent changes at home, school, or relationships that may be relevant?
Who currently lives at home with the child/young person?
Section 7: Wellbeing & Safety
Are you/your child currently experiencing any thoughts of self-harm or suicide?
*
Are there any current concerns around emotional wellbeing or safety?
*
Are there any current safeguarding concerns or risks to others, or agencies currently involved(e.g. Social Care, school safeguarding team)?
*
Is anyone else involved in your/your child's care at the moment? (e.g. GP, mental health team)
*
Section 8: Hopes & Goals
What would you/your child/your family hope to gain from counselling or coaching?
*
Is there anything else you feel it would be helpful for me to know?
Section 9: How did you hear about The Healing Space? (Required)
*
Psychology Today
BACP Directory
Counselling Directory
Creative Counsellors
Instagram
Facebook
Recommendation/Word of mouth
Other
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