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 362540 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.
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.

"*" indicates required fields

Consent Statement*

I give consent for the personal and sensitive 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 deleted after 6 months.

Yes

Unfortunately, we are not able to continue without your consent.

Please ring the office on 01206 791661 and if you get the answerphone please leave a message so we can ring you back.

Alternatively, with consent you can continue with our Online Counselling Enquiry.

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

Contact & Personal Details

Your name:*

Child/Young Person name:*

Your name:*

For Couples Counselling we require both clients to complete a form.
Please ask your partner to complete an enquiry form.

2nd Client name:*

This is to enable us to collate your Counselling Enquiry Forms.

Please state your preferred pronoun:*

She

They

Prefer not to say

Please state your child's preferred pronoun:*

She

They

Prefer not to say

Age:*

Date of Birth*

Please confirm the child can attend face to face sessions as remote counselling is not available for child clients aged 15 and under*

I confirm the child can attend face to face

Is the young person able to come for face-to-face counselling or do they need remote counselling either by telephone or online?*

Face-to-Face

Telephone

Online

You have selected remote counselling, does the young person have a private, quiet, confidential space free from interruptions that is available each week, and is not a car or public place?*

Yes

What is your address?*

Street Address Town/City Postcode

What is your child's address?*

Street Address Town/City Postcode

Your name:*

Relationship to client:*

What is your contact phone number?*

When are the best times to ring you back?*

Please choose as many options as possible to receive a call from our referral team.

9.00am - 11.30am

1.00pm - 2.00pm

2.00pm - 3.15pm

What is your email address?*

Enter Email Confirm Email

Please select all the options we can contact you by:*

Telephone

Text

Voicemail

About The Counselling

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

Online

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

As this is 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.

Yes

Please provide name of 2nd Parent/Carer:*

Contact phone number for 2nd Parent/Carer:

How did you hear about the LIFE-FORCE Counselling Service?*

Do you know anyone else who’s been to LIFE-FORCE for counselling?*

Yes

Are you currently receiving counselling or therapy elsewhere?*

Yes

On a waiting list

Other

Is the child currently receiving counselling or therapy elsewhere?*

Yes

On a waiting list

Other

Have you ever had counselling before?*

Yes

Has the child client ever had counselling before?*

Yes

Did you find it helpful and if so in what way? Or what didn't work/how would you like it to be different?*

Did they find it helpful and if so in what way? Or what didn't work/how would they like it to be different?*

Please select UP TO 5 OPTIONS below that best describe your reason(s) for seeking counselling:*

Please select UP TO 5 OPTIONS below that best describe their reason(s) for seeking counselling:*

What do you feel is the main presenting issue for seeking counselling:*

Do you wish to see a male or female counsellor or do not have a preference?*

Male

Female

Either

How much can you comfortably afford to pay on a regular weekly basis?*

(We may have a waiting list to see a Student Counsellor)

£10 - Student Counsellor

£35 - £45 - 1-2 years Qualified

£50 - £55 - Over 2 years Qualified

£60 - £70 - BACP Accredited

How much can you comfortably afford to pay on a regular weekly basis?*

N.B We will need to speak to both of you in order to arrange an appointment. The range for Couple Counselling is: £45 - £70 Couple Qualified (depending on experience)

Please enter a number from 45 to 70.

How much can you comfortably afford to pay on a regular weekly basis?*

N.B We will need to speak to both of you in order to arrange an appointment.

£35 - £55 - Child/Young Person Qualified

£60 - £70 - BACP Accredited

What days and times can you attend at a regular time each week?*

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

Sundays

Mondays: Please let us know the earliest - latest appointment start times. E.g. 9am-8pm (leave by 9pm). Sessions last 50 minutes.

Tuesdays: Please let us know the earliest - latest appointment start times. E.g. 9am-8pm (leave by 9pm). Sessions last 50 minutes.

Wednesdays: Please let us know the earliest - latest appointment start times. E.g. 9am-8pm (leave by 9pm). Sessions last 50 minutes.

Thursdays: Please let us know the earliest - latest appointment start times. E.g. 9am-8pm (leave by 9pm). Sessions last 50 minutes.

Fridays: Please let us know the earliest - latest appointment start times. E.g. 9am-8pm (leave by 9pm). Sessions last 50 minutes.

Saturdays: Please let us know the earliest - latest appointment start times. E.g. 9am-8pm (leave by 9pm). Sessions last 50 minutes.

Sundays: Please let us know the earliest - latest appointment start times. E.g. 9am-8pm (leave by 9pm). Sessions last 50 minutes.

Do you have any disabilities or health conditions that we need to be aware of?*

Yes

Please provide further details:

Do you or the child have any disabilities or health conditions that we need to be aware of?*

Yes

Please provide further details:

Do you have any other specific counselling requirements or special needs?*

Yes

Please provide further details:

Do you have any other specific counselling requirements or special needs?*

Yes

Please provide further details:

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.

WAITING AREA - I understand when I come for my first session I can wait in the Rainbow Room and my counsellor will come and meet me there. For further sessions, I will aim to come on time or wait in the Rainbow Room, and then go straight to the therapy room at my appointment time.

HEALTH & WELL-BEING POLICY – If I am unwell and unsure if I should attend my appointment, I will read the Health & Well-being Policy on the website before contacting my counsellor.

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.

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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