Initial Consultation Form

Where did you hear about me? Do you suffer with any of the following health problems: AlcoholismAsthmaCancerDiabetesHeart ProblemsHepatitisHigh blood pressureMental healthOsteoporosisEpilepsyStrokes Are you on any medication, if so please list: How is your current state of health: Any operations in the last year or any pending? YesNo Stress Level 1 – 10 (10 being very high): 12345678910 Emotional and psychological state of mind 1 – 10 (10 being not well): 12345678910 Physical well being 1 – 10 (10 being very poor): 12345678910 Physical activities: exercise / mobility: Reason for treatment and therapeutic goals? Anything else you would like to add:

PLEASE READ BELOW BEFORE SIGNING

A counsellor is not a doctor or a psychiatrist and therefore will not diagnose or treat any physical or severe mental health issues, such as schizophrenia. If you suffer with these please seek the appropriate health care.

By signing you are offering your commitment to our work together. We will review after 4 sessions. Please be aware that therapy may stir things up and there maybe a temptation to give up, but this will pass, and things should start to improve. If you are not feeling improvement after a few months, please let me know as this therapy might not be the right one for you.

Counselling can be a long process, depending on what you are needing to address in your life. It has taken us such a long time to form patterns, and can take time to undo them. However it can also be a quick process and it may only need a few sessions.

CANCELLATION POLICY

If you do not cancel within 24 hours or do not show up for a session there will be a cancellation fee of £25 to cover my loss of time and the opportunity to offer others that space.

By signing you agree to the above terms and are also happy for your information to be kept under the General Data Protection Regulations 2018.

Everything discussed in our sessions will remain confidential, unless there is a safe guarding issue.

I have read and understood the above. I have had the treatment I am receiving today explained to me.