St Martin's Counselling - Accessible, Professional, Affordable Counselling Sessions

To help us support you in the most effective way, please complete this self-assessment form. The information you provide will give us a better understanding of your needs, any areas you’d like to focus on and what you hope to achieve from counselling.

Please answer as openly and honestly as you feel able, your responses are confidential and will only be used to enable us to allocate you to the right counsellor.

Please see our Exclusion Criteria for certain issues that we cannot provide support with.

Please note our free service is limited to a small number of applicants each month and is limited to 6 sessions.

Thank you.

Self Referral Form

First Name *

Last Name *

Email Address *

Phone Number *

Address *

Street address *

City

Postcode *

Date of birth *

How old are you? *

Gender identity

GP surgery *

Why do you feel you want counselling at this time? *

What are you going through? *

How is it affecting your life day to day? *

What would you like to get out of counselling? *

If you have indicated that you have experienced any of the above, can you give us more details *

Do you have anybody you can talk to about these issues at the moment, friends? family? work colleagues or your GP? *

Are you on any relevant medication or do you have a diagnosed mental or physical health condition that may affect your ability to engage with counselling? If yes, please share some details. *

Please tell us about any previous counselling or therapy you may have received including employee assistant programmes

How would you prefer to be contacted? *

PhoneTextEmailLetter

What type of appointment would you prefer? *

Face to FaceRemoteEither Face to Face or Remote

We have a limited number of remote appointments on Saturday morning between 9am and 2pm. Please tick if you are available for an appointment at this time.

YesNo

Please give us details of someone you are happy for us to contact in case of emergency, name and contact number

How did you hear about St Martin's Counselling? *

If you selected 'Other', please specify how you heard about this service