← Adult Counselling

Client Information Form

Please complete this confidential form to help our counselling team understand what support you are looking for.

Before you begin

This form is for people aged 18 and over seeking counselling for themselves. It asks for personal and wellbeing information so that we can consider your enquiry and arrange an appropriate initial appointment.

Please only provide information you are comfortable sharing. Your information will be treated confidentially and accessed by the team responsible for your enquiry.

Wessex is not a crisis service. If you or somebody else is in immediate danger, call 999 or attend your nearest A&E department. For urgent emotional support, call Samaritans free on 116 123.

Your information

Fields marked with an asterisk are required. We will contact you after reviewing your submission.

Full name *

Date of birth *

Pronouns (optional)

Home address *

Postcode *

Email address *

Phone number *

Preferred way for us to contact you *

Is it safe to leave you a voicemail? *

Emergency contact name and phone number *

GP name and surgery *

What brings you to counselling at this time? *

Are you currently receiving support from any other service?

Please tell us about any medication relevant to your wellbeing

Have you had counselling or psychotherapy before?

Preferred session format *

Preferred location *

Days and times you are usually available *

Approximate annual personal income *

Accessibility or communication needs

I consent to Wessex Counselling & Psychotherapy contacting me about this application. *

I understand that the information I provide will be used to assess my counselling enquiry and stored confidentially. *

Useful Information

Fees and Appointments → Payments →