Counselling form

Request form for Specialist Counselling

About You

First name

Last name

Date of birth


How would you describe your gender?

Do you have children under 18 years old in your care?


Home phone number

Mobile phone number

Preferred method of contact (you can choose more than one)

Home PhoneMobileEmailTextVoice message on mobile is OK

Your Current Situation

We want to understand your situation as much as possible so that we can help you in the most effective way. Please
complete all the questions as fully (but briefly) as you- can. This will help both you and your counsellor prepare for the session. Your responses are confidential!!

What has led you to seek Counselling Service at this time?

How long have you been experiencing your current difficulties/concerns?

How well have you been coping recently? (e.g. sleep, drug & alcohol use, eating, exercise)

What are your thoughts about what might be contributing to your present difficulties/concerns? (e.g. what might be keeping the problem going?)

What would someone who knows you well say is different about you now? (if anything)

What strategies have you tried to help you cope either now or in the past?

For counselling to be helpful for you, what changes would you see occurring in your life?

Is the overuse of alcohol and/or drugs a significant coping strategy for you at present?

What do you consider doing at particularly bad moments?

Are you currently experiencing suicidal thoughts?


If yes, how often do you feel like this and would you be likely to act on it?

Where do you get support from? (e.g. family members, friends, a partner, (pet(s), groups/clubs?)

How would you know that things were better? What changes would you notice about your thinking, and how you are feeling and behaving that would indicate things are better?

In this space please include anything else you feel it is important for us to know

Have you sought help for this difficulty from your GP?


Please use this space to provide details of any medical condition or psychological diagnosis you have that you feel we should be aware of. Please list medication you are taking.

If you have received professional help for this or any other problem in the past, who has provided this (select all that apply)

Counsellor/PsychotherapistPsychologistPsychiatristGeneral PractitionerMental Health TeamStudent Health & CounsellingOther

if other please specify

Do you have a preference for a particular counsellor? (e.g. male, female, or a specific person). This may make arranging an appointment slightly slower but please state preferences with reasons if appropriate below.

Attending Appointments

We are nearly finished - we don't need much more info now

To give us some idea of your availability please indicate when you would be able to attend appointments (please choose more than)