28 Highbury Grove, London, N5 2EA

Tel: 020 7354 4791Fax: 020 7354 3221Email:

APPLICATION FORM FOR COUNSELLING

PRIVATE & CONFIDENTIAL

If you have any difficulty in completing this form, please contact us

HCC Ref:

Title:……………………………………..….…………………………………………………………………………………………………………

First Name:………………………………………………………………………………………………………………………………………….

Surname:……………………………………………………………………………………......

Address: ……………………………………………………………………………………………………………………………………………

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…………………………………………………………………………………………………………………………………………………………….

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Tel. numbers: Daytime/Mob:……………………………Can we leave a message? 

Evening:……………………………………..Can we leave a message? 

Email address: …………………………………………………………………………………………………………………………………….

Gender: MaleFemale 

Date of Birth: ……………………………………………….Age: …………………………………………………..

I would like to book an assessment and enclose a non-refundable payment for my assessment fee:
(cheque payable to HCC- WLM)
£40 (in employment)
£20 (unemployed, retired, student)

Please explain briefly why you would like counselling. What do you see as your current/most urgent problem(s) to address?

Have you sought counselling before? Please tell us when, where and whether you have found it useful:

How did you hear about Highbury Counselling Centre? Did someone refer you to us?

Client’s availability for counselling

Please indicate the days and times you are available for regular weekly counselling sessions. The more choices you give the sooner we will be able to allocate you a counsellor.

Time / Mon / Tues / Wed / Thurs / Fri / Sat
9.00-10.00
10.00-11.00
11.00-12.00
12.00-13.00
13.00-14.00
14.00-15.00
15.00-16.00
16.00-17.00
17.00-18.00
18.00-19.00
19.00-20.00
20.00-21.00

Medical Details

If you start counselling at HCC, your counsellor will normally write a courtesy letter to your GP letting them know this. The counsellor would not communicate further with your GP without your knowledge; we would like permission for them to write this initial letter. If you do not wish to give consent, it can be discussed during your first appointment.

I give HCC permission to make contact with my GPYES / NO

Name of GP:………………………………………………………………………………………………………………………………………..

Address:…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Have you ever received psychiatric treatment and/or medication? YES / NO

Please give details here:

If you are currently receiving psychiatric treatment, we must have your permission to contact your psychiatrist to confirm it is appropriate for us to offer you counselling.

I give HCC permission to make contact with my psychiatrist YES / NO

Name psychiatrist:……………………………………………………………………………………………………………………………..

Address:………………………………………………………………………………………………………………………………………………

Tel: …………………………………………………………………………………………………………......

Income

HCC was established to provide affordable counselling to members of the local community. Our intention is to make counselling and psychotherapy available to those people who need it, regardless of ability to pay. We ask all clients to pay a fee based on their capacity to contribute on a sliding scale.

This will be discussed at your counselling assessment.

Please indicate whether you are: Employed-indicate annual income £……………

Unemployed

Retired

Receiving benefits

Other

Do you have any special requirements that would assist us to help you?

Confidentiality/Data protection:

Highbury Counselling Centre will keep my application form and notes from my assessment session in a locked and secure file. Such information will not be disclosed to any third party except where required by law or at my request and may be kept for up to 10 years.

Highbury Counselling Centre is a member of the British Association for Counselling and Psychotherapy and abides by the BACP Ethical Framework for Good Practice.

I understand and accept the above:

Name and signature……………………………………………

Date: ………………………………………………………………….

Please return this form and payment to:

Highbury Counselling Service

Counselling Coordinator

28 Highbury Grove, London N5 2EA

November 20161