Counselling request form

Personal Details

Contact Details

Questions

Your First Name

Your Last Name

What do you identify as?

Date of Birth

How would you describe your ethnic origin?

House Name/Number

Street Name

Town/City

Postcode

I give permission for Mid and NE Essex Mind to store my data

Please fill out these contact details so we can get back to you.

What is your Telephone Number?

What is your Email Address?

Can we leave a voicemail?

Which GP surgery are you registered with? When are you available (Days/Times)

How would you prefer to meet? Face to FaceTelephoneVideo Call

How did you hear about our service?

How are you currently feeling?

Overall, how is your mood? (0: Very Bad, 10: Very Good)

( Min : 0 - Max : 10 ) 100

Overall, how are you coping? (0: Coping badly, 10: Coping well)

( Min : 0 - Max : 10 ) 5

Fill out these questions as much as you can, the more questions we have the better we can help!
1. How do you feel at this moment? What is the reason you wish to seek counselling?
2. Who is supportive in your life? E.G. Family, Friends, Colleagues etc.
3. Have you received counselling before?
Please tell us how this experience was for you?
4.What do you want to achieve from counselling? What are your goals? 5. Are you currently being supported by a mental health team or any other organisation?
Please provide details of current mental health support.
6. Are you being prescribed any medication for your mental health?
Please list what medication you are receiving related to your mental health, including dosage and frequency.
7. Do you have a mental health diagnosis?
Please give details about your mental health diagnosis
8. Do you currently self-harm or have suicidal thoughts?

You're not alone. For immediate help, click this link. To continue with your referral - please select the Request Counselling button below to complete your referral.