START

Thank you for your interest in receiving counselling with us, before taking you to the application we would like to clarify a few points, kindly tick each statement to indicate you have read and understood it.

I understand that by completing this application form, I am applying for counselling services at the Centre for Better Health, which may include an assessment interview:

I understand that I may receive counselling from a counsellor in training:

I understand that my counsellor will attend supervision and may discuss aspects of my case in confidence:

I understand that all information shared with the service is confidential and no information will be released without my consent. However, I understand that confidentiality may be broken in the following circumstances: risk to self, risk to others and safeguarding of vulnerable persons. In the first instance, this might be with your GP or with a local safeguarding board:

I understand that the centre will not offer counselling therapy to counselling students who are seeking therapy solely to fulfil their course requirements and no written confirmation of attendance will be issued under these circumstances:
If you are currently enrolled as a counselling student please supply details here:

Please note that if you are accessing counselling to address adoption issues, eating disorders, substance misuse or bereavement we would advise you to contact other specialist counselling services.

We will now take you to the application; kindly complete all sections as thoroughly as you can.

PERSONAL DETAILS




Home Address:
Door number and Street:
Post Code:
Borough*:

* Due to increased demands on our service, we are currently only accepting applications from the Boroughs of City and Hackney, Haringey and Tower-Hamlets

It is important that we are able to contact you by email and phone to invite you to your appointment and to obtain more information if needed. Please give those details below:

Is it OK to leave a voice message?:

Note: We require the details of a person to contact in case of emergency as well as your GP's. Please give details below.
Emergency Contact:
Name and Relation to you:
Emergency Contact Phone Number:

GP/Surgery details:
Name:
Address of GP:

Have you received counselling before?:
If yes, please indicate with which provider(s)

To select multiple options:
For Windows: Hold down the control (ctrl)+ select
For Mac: Hold down the command button

:
Please give us some details about the counselling you have receive in the past (length, dates, other provider):
Are you currently receiving counselling from another organisation?:
If yes, please provide details:

SELF ASSESSMENT

Date of Birth (format dd/mm/yyyy):
Gender:
Gender - self description:
Relationship Status:
First Language Be aware that unfortunately we do not work with interpreters:

Have you ever been admitted to hospital experiencing mental distress?:
If yes, please give details:
Have you ever been diagnosed with a mental illness?:
If yes, what was the diagnosis:
Have you ever been prescribed medication for mental health issues?:
If yes, please give details:
Are you currently taking any medication?:
If yes, please give details:
Please indicate issue(s) that apply to you:

Aggression: Anxiety: Bereavement: Depression: Domestic Problems:
Emotional Difficulties: Panic Attacks: Post Traumatic Stress Disorder:
Relationship Problems: Stress:
Multiple Factors (please explain below): Other (please explain below):


Please give a brief description of the issues you wish to address in counselling and any other information you feel we need to know. If you have ticked other or multiple factors you can tell us more here:

AVAILABILITY AND FEES

Please note that it is important to state the days and times you are able to commit to regular sessions.

Once an appointment has been confirmed, we are unable to reschedule this without returning your application to the waiting list. This includes being reallocated from a daytime to an evening appointment

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

These measures are in place to help us reduce waiting times and to deliver our services as efficiently as possible.

I have read and understood these statements:

Fees:
We charge counselling sessions weekly on a sliding scale based on your employment status for the exception of evening sessions which are always £25.


What is your current Employment Status?
Preference for gender of counsellor (no preference increases availability):

DAYTIME APPOINTMENTS Please indicate as many options as possible

To select multiple options:
For Windows: Hold down the control (ctrl)+ select
For Mac: Hold down the command button+select

Any Daytime appointment / at Any Time:

Daytime Monday Time:
Daytime Tuesday Time:
Daytime Wednesday Time:
Daytime Thursday Time:
Daytime Friday Time:

EVENING APPOINTMENTS please indicate as many options as possible

To select multiple options:
For Windows: Hold down the control (ctrl)+ select
For Mac: Hold down the command button+select

Any Evening / Any Time:

Evening Tuesday Time:
Evening Wednesday Time:
Evening Thursday Time:

How did you hear about us?:


Optional: you do not need to fill in the following questions if you do not wish to, however we appreciate if you do, as it helps us to ensure that our services reach the widest possible audiences and that they are available to sections of the public that may be underrepresented. This part of the application will be kept separately and anonymously for monitoring purposes only.

Ethnicity:
Ethnicity Sub Category:
Religion or Belief:
Other Religion or Belief:
Sexual Orientation:

CONSENT

Thank you for completing this application, we use all information in accordance with the data protection act.

Kindly type your name below to consent to your information being processed by us.

Consent:

Please click here to access our policy about how your personal details will be handled.

You can withdraw your application at any time by emailing: counselling@centreforbetterhealth.org.uk

To submit your application click "SUBMIT" OR "SUBMIT QUERY"