Counselling Enquiry

  • This Counselling Enquiry form must only be completed by the client or by a parent of a child/young adult client.
  • We will still need to speak to you and take some further personal information but by completing this form it will reduce the time spent on the phone.
  • It will only take a few minutes to complete.
  • Alternatively you can email the office, and provide your phone number, and we will go through all the referral questions on the phone with you.
1.

I give consent for the personal information provided below to be used by the LIFE-FORCE Counselling Service for the sole purpose of finding me/the client the right counsellor. It will be electronically deleted/shredded after the details are confirmed over the phone by one of the office staff.

If NO, please do NOT continue instead ring the office on 01206 791661 and if you get the answerphone please leave a message so we can ring you back.

2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Tick below and write your preferred fee per session.

£8.50 Student Counsellor
£
£25 - £35 1-2 years Qualified
£
£40 - £45 Over 2 years Qualified
£
£50 - £60 BACP Accredited
£
£35 - £45 Couple Counsellor
£
£50 - £60 BACP Accredited
£
£30 - £45 Qualified Child Counsellor
£
£50-£60 BACP Accredited
£
15.

For each day of the week please state the earliest time and latest appointment time. E.g. Mondays 3pm-7pm (leave by 8pm). Sessions last 50 minutes.

16.
17.

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 ASAP. In the meantime, please contact the office on 01206 791661 should you wish.

Captcha