The LIFE-FORCE Centre provides Face-to-Face counselling, however we are also able to offer Telephone & Online Counselling.

Please note we are unable to offer counselling for situations where the focus of the work is an adoption-related issue.

Contact LINK BARNARDO'S on 01206 362 540 or email link.referalhub@barnardos.org.uk

Counselling Enquiry Form

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.	Consent Statement I give consent for the personal information provided on this Counselling Enquiry Form to be added to a Referral Form paper copy by the office and for it to be shared within the Counselling Service in order to find me/the child a suitable counsellor. I understand it will be treated confidentially and that this Counselling Enquiry Form will be electronically deleted after 6 months. Yes No 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.	Are you able to come for face-to-face counselling or do you need remote counselling either by telephone or online? Face-to-Face Telephone - only available for clients aged 16 years and above Online - only available for clients aged 16 years and above
3.	If you require remote counselling, do you have a private, quiet, confidential space free from interruptions that is available each week, and is not a car or public place? Yes No N/A
4.	Which of the following categories apply to the client? Adult Person over 18 years old Couple - Please ask your partner to also fill in a form Child/Young Person under 18 years old
5.	a) What is your name/child client’s name, age and date of birth? b) If you require couple counselling, please provide the initials of your partner so we can collate your Counselling Enquiry Forms. c) If you are the parent of a child client, please provide your name and state relationship to client. d) For child counselling is the 2nd parent/carer in agreement about the counselling? If they are not in agreement or you are unable to inform them then, depending on the legal circumstances which we will discuss with you on the phone, the sessions may or may not be able to go ahead.
6.	Please state your/your child's preferred pronoun He She They Prefer not to say
7.	What is your/child client’s address?
8.	What is your contact phone number? (Enter at least one number) Please tick the box to confirm we can ring you, text and leave voice messages from the counselling service on the number you have provided above.
9.	When are the best times to ring you back? Please choose as many options as possible to receive a call from our referral team before 3.30pm. 9.00am - 11.30am 1.00pm - 2.00pm 2.00pm - 3.30pm All of the above times
10.	What is your email address? Please confirm your email address Please tick the box to confirm this is a private, confidential email address and that we can contact you on this if necessary.
11.	How did you hear about the LIFE-FORCE Counselling Service?
12.	Do you know anyone else who’s been to LIFE-FORCE for counselling? Yes No
13.	Are you/the child client currently receiving counselling or therapy elsewhere? Yes No On a waiting list Other
14.	Have you/the child client ever had counselling before? Yes No
15.	Do you/the child client have any physical disabilities that make it difficult or impossible to climb stairs? Yes No
16.	Select up to 5 options below that best describe your reason(s) for seeking counselling: Abuse Addictions Anger Issues Anxiety Autistic Spectrum Disorder Bereavement & Loss Bullying Childhood Issues Cognitive / Learning Disability Communication Disorders Crisis Death & Dying Depression Divorce Domestic Violence Eating Disorders Family Conflict Gay & Lesbian Issues General / Everything Health Issues Living / Welfare Problem Mental Health Condition OCD Panic Attacks Past Issues Personality Disorder Post-Natal Depression Post-Traumatic Stress Disorder Rape Redundancy Relationships Self-Esteem / Low Confidence Self-Harm Separation Sexuality / Gender Special Needs Stress Suicidal Trauma Work / Academic / Training Requirement Other
17.	Do you/the child wish to see a male or female counsellor or do not have a preference? Male Female Either Male or Female
18.	How much can you comfortably afford to pay on a regular weekly basis? Tick below and write your preferred fee per session. a) Adult Individual Counselling £9.50 Student Counsellor £ N.B We may have a waiting list to see a Student Counsellor. £35 - £40 1-2 years Qualified £ £45 - £50 Over 2 years Qualified £ £55 - £65 BACP Accredited £ b) Couple Counselling N.B We will need to speak to both of you in order to arrange an appointment. £45 - £50 1-2 years Qualified £ £55 - £65 Over 2 years Qualified £ c) Child/Young Person Counselling £35 - £40 1-2 years Qualified £ £45 - £50 Over 2 years Qualified £ £55 - £65 BACP Accredited £
19.	What days and times can you/the child client attend at a regular time each week? 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. Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays Shift Worker
20.	Do you have any other specific counselling requirements or special needs?
21.	Please confirm all the following points: RISK ASSESSMENT - I understand this may be considered necessary to keep me/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 - The Centre is on East Hill between St James Church and Priory Street. DOOR CODE – '2512' (Christmas Day) I will keep this in a safe place so that I can let myself into the building upon arrival and will not share this with anyone else. APPOINTMENT TIME – I understand when I come for my first session my counsellor will meet me in the foyer. After that I will arrive on time and go straight to the therapy room as there is currently no waiting on the premises permitted. COVID-19 POLICY – I understand wearing a facemask in the public areas of the building is optional, and I will bring my own face covering if needed and will discuss with my counsellor whether or not to wear this during the session. Also, I will read the Centre’s Covid-19 Policy on the website should I wish to do so. PAYMENT – I understand I can pay by cash or possibly by BACS, but cheques and credit cards are not accepted. I will discuss this with my counsellor before our first appointment so that I can pay them directly. IF I CHANGE MY MIND – I give my consent for the Service to retain my information for 6 months in case I wish to return. EMERGENCY SUPPORT – If I need this before my first appointment I understand I can phone the Samaritans on 116 123 or call NHS 111.
22.	Thank you for completing this form. When submitted you should receive a Confirmation Enquiry Successfully Submitted response followed by an automated email reply. If not please try again or let us know by email info@lifeforce-centre.co.uk Once we receive your completed form 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.

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