Get started on your journey with St. Martin's Counselling

Thank you for reaching out. This form will help us understand your needs and match you with the right counsellor.

All the information you provide is held securely and only seen by authorised staff to allocate you to a counsellor. You can find more in our Privacy Policy.

Please complete this form as fully as possible. If we have to come back to you for more information, it may slow down you getting the counselling you need.

Please be aware that we are not a crisis service, and there are also some serious mental health conditions requiring medical treatment that we cannot provide support with.

We know that cost is often the most significant barrier to accessing the professional support you need. Our heavily subsidised fee is £25 per session

I understand there is a £25 fee per session. *

About You

First name *

Last name *

Email Address

Phone number *

Date of birth *

Your age *

Address *

Street address *

City *

County *

Postcode *

Gender identity (optional)

Pronouns (optional)

Where did you hear about us? *

Other

Your Emotional Needs & Goals

Something else

Can you tell us a bit more about how this is affecting you? *

What would you like to get out of counselling? *

Preferences

Preferred session format *

In-person at St. Martin's Counselling in BirminghamOnlinePhoneNo preference

Preferred contact method *

PhoneTextEmail

Your Safety

We take your safety seriously, and ask the following questions to help us offer extra support if needed.

In the past 3 months, have you experienced any of the following? *

Can you tell us some more information?

Would you feel comfortable sharing your GP's details in case of a safeguarding concern? *

Yes, I'm happy to provide GP detailsNo, I'd prefer not to

GP Name

Surgery or practice

GP Contact number (if known)

Emergency Contact Name

ICE Phone number

Relationship to you

If you have ticked one of the boxes above, we require you to supply us with your GP details but please be assured that we will only use them in case of emergency.

GP Name *

Surgery or practice *

GP Contact number (if known) *

Emergency contact name *

ICE Phone number *

Relationship to you *

Are you receiving any additional support for your mental health? *

YesNoPrefer not to say

If yes, please share anything you feel comfortable with