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

Can you tell us more about yourself and why you are looking for counselling.

Please can you give as much detail as possible to these questions. Tell us how you are feeling, details about your situation and challenges and what you want to get from counselling sessions.

It is important to give as much detail as possible to help the team assess your needs and allocate you to a counsellor.

Please note you are applying for a fee paying service.

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

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

Our low cost counselling fee is £25. We do offer a concessionary rate for those unwaged or on benefits. Please indicate which fee you will pay. We will then require evidence to apply the concessionary rate.

Please tick the fee you will pay *

£25 fee£15 concessionary fee

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