Before Counselling Starts

I will need the following Information before Counselling begins.

Your Details

• Name:
• Date of Birth:
• Address:
• Phone Number:
• Email Address:

Emergency Contact Details

• Name:
• Relationship:
• Phone Number:

GP Details (optional)

• Surgery Name:
• Phone Number:

Session Format Preference

☐ In person ☐ Telephone ☐ Online

Current Support

Are you currently receiving any other form of counselling, therapy, or mental health support?

Medication

Are you currently taking any medication that may be relevant to your wellbeing?

Reason for Seeking Counselling

What has brought you to counselling at this time?

Health Information (optional)

Is there anything about your physical or mental health that you feel would be helpful for me to know?

Additional Information

Is there anything else you would like to share before our first session?

GP Contact Consent (optional)

In rare situations where there are serious concerns about safety or wellbeing, it may be helpful to contact your GP or relevant services.

☐ I consent to my GP being contacted if necessary for safety reasons.

Signature:

Date: