New Patient Registration consent Statement* Yes I give consent for the personal information below to be used by Life In Action Limited for the purpose of helping the client find the right counsellor. It will be deleted/shredded after the details are confirmed and processed with the office and when/if you take up counselling with one of the team. This is inline with our data policy. Which of the following categories apply to the client?* Adult person over 18 years Couple A young person or child under the age of 18 What is your name/child client’s name, age and date of birth? Please provide your details so we may contact you If you are the parent of a child client, please provide your name and state relationship to client.*Address detailsWhat is your/child client’s address?Telephone number/s* What is your contact phone number? (Enter at least one number) Please tick the box to confirm we can contact you on and leave messages from the Service on the above number(s)How did you hear about the Life In Action Counselling Service?*I came across you on Google searchGP referralI was told about you from a friend or family memberI found you on the BACP registerI have seen one of your therapists in the pastPlease let us know how you came to contact us. e.g a Dr referred you to us or you were passed our number from someone you know. Do you know anyone else who’s been to Life In Action for counselling?YesNoAre you/the child client currently receiving counselling or therapy elsewhere?*YesNoOn a waiting listPlease tell us if you are receiving some other support Have you/the child client ever had counselling before?*YesNoSpecial needs and Disability*YesNoRather not sayDo you/the child client have any physical disabilities that make it difficult or impossible to climb stairs?Areas of support Abuse Anxiety Addiction Autistic spectrum disorder Childhood issues Cognitive / learning disability Depression Divorce Family conflict LGBTQ+ related General mental health Personality disorder (PD) Rape Covid 19 related (2020) Redundancy Self-harm Separation issues Anger issues Bereavement & loss Bullying Death & dying Eating disorders General / everything Health issues OCD Mens related issues Womens related issues Identity issues Panic attacks Post-traumatic stress disorder (PTSD) Relationships Self-esteem / low confidence Suicidal Stress Other Select the main option below that best describes your reason for seeking counselling:Do you/the child wish to see a male or female counsellor or do not have a preference?*MaleFemaleI have no preferencelet us know and we will try to match you where we can to the right therapist. This may depend on the issues you are facing. We will discuss this with you before any agreement is sought. Costs*£70.00- 80.00 BACP Accredited£85.00-90.00 Relationship and Family CounsellingHow much can you comfortably afford to pay on a regular weekly basis? We may have a waiting list for some counselling AvailabiltyMondayTuesdayWednesdayThursdayFridayWhat days can you/the child client attend at a regular time each week? For each day of the week please state the best day for you. If you have a set time you are looking for please indicate this in the section below. Special requests for time Please let us know if you have a specific time you are looking for on a set day. Special pointsRISK ASSESSMENT - This may be considered necessary to keep you/the child client safe.NO CHILDREN - can be left unattended on the premises.COUNSELLOR’S PHONE NUMBER - I will keep this in a safe place so that I can contact them directly to cancel and re-arrange sessions.DIRECTIONS TO THE CLIINIC - I will ask the office for these if needed.Please confirm all the following points: Do you have any further information you would like to provide us in order to help you find the right support with Life In Action Thank you for completing this form. Once submitted a member of the office staff will contact you within 1-2 working days to confirm your details with a view to arranging an appointment for you as soon as possible. In the meantime, please contact the office on 01476 575933 should you wish. Regards, Life In Action Counselling Team Email* PhoneThis field is for validation purposes and should be left unchanged. Δ
