Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Gender
*
Male
Female
Other (please specify)
Phone
*
Country
(###)
###
####
Can you be contacted by phone?
*
Yes, calls and messages
Yes, calls only
Yes, messages only
No
Preferred language
*
Preferred counselling method
*
Note: Priority will be for face-to-face sessions.
Disabilities
*
Relationship Status
*
Never been in a relationship
Currently in a relationship
Was in a relationship
Referred by:
*
GP
Self
Other (please specify)
GP Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Main presenting problem
*
To make an appropriate treatment decision, it is important to receive as much information as possible. Please write specific details here, and send any additional information to randa@ruh-counselling.com.
Counselling history
*
Have you previously received counselling, psychological therapies or input from any other mental health service? If yes, please provide details.
When would you like to start your counselling sessions?
*
Due to high demand, I will be working in with 6 clients at a time. Each group of clients will run for 6 weeks, with weekly sessions.
Each new group will start with the beginning of a new term/half-term, to make sure your 6 sessions are as uninterrupted as possible.
The first session will start on Tuesday, 6 January, 2025.
Alternatively, if you feel you need counselling sooner, I would be happy to provide you with a referral to a trusted colleague who may have immediate availability.
To help me allocate you a space, please let me know when would you prefer to start:
The sessions will take place on the agreed time and date and will be with a trainee counsellor who follows an ethical framework.
*
