Counselling Information Form

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This form is designed to collect all necessary information needed to commence counselling with In Toto Counselling.
Please complete this with as much information and accuracy as possible.

We will be in touch as soon as possible to discuss suitability and arrange an free 30 minute initial session.

Please allow 3-5 working days for someone to contact you, thank you

Email *

Date Form Completed *

YYYY

Full Name (including preferred name if different to legal name): *

Date of Birth *

YYYY

Home Address including post code *

Gender (please choose which you identify as) *

Preferred Pronouns *

Telephone Number *

Best day and time to contact you *

Please confirm if we are able to leave a voicemail on this number *

Yes

Required

Email Address *

Please enter your GP details and surgery details including address and telephone number *

If you are not registered with a GP, we can offer you a initial assessment session however you will be to be registered with a GP before counselling sessions commence.

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