Self Referral Form and Assessment - One Step Counselling and Therapies C.I.C.
This form is for anyone who would like to refer themselves for consideration for low cost/free counselling. Please note, if you are not successful in being placed on one of our waiting lists after completing this form, that we will delete this form and any data we hold on yourselves. All information will be kept confidential unless there is a serious level of risk, of harm to yourself or others.
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Full Name *
Telephone Number *
Email Address *
Do you have a stable internet connection, and a device capable of video calls? *
If no, or if you would prefer to take a telephone call for counselling, please state below *
In a few words, what would you describe your reason for seeking counselling? *
Do you have ANY addictions? (even if it may be something such as food, mobile phone etc, it does not have to be alcohol or drugs) *
Do you consider yourself to be at risk of self harm, or suicide? *
if yes, how would you consider your risk? *
If you feel you are at immediate risk of suicide, or harming someone else, please contact 999 urgently. *
Do you have any current medical or mental health diagnosis? *
What is your usual availability for counselling? (If this changes week on week, please provide the next two weeks availability, and if we cant book you in in that time if our waiting list is longer, we will call you to check your availability at a later date, lower availability means there will be less counsellors we can match you with) *
What is your total household income, including anyone who lives with you (including income for any children who live with you). This can be subject to checks and should not be falsified. *
Have you had any previous counselling, and if so, what kind, and did you find it effective? *
Thank you for completing this form, please enter the date and your name as way of signing this form, and to provide permission to use your data provided purely for assessment for the counselling service we provide. We will contact you as soon as possible to arrange counselling, wait times do vary. *
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