To arrange an initial Couple Counselling appointment in our Covent Garden venue, please complete the registration form below providing us with some information about yourself and what you are hoping to achieve through the process. We will then consider your request and offer you an initial consultation with the Heart & Team member best suited to your individual needs and preferences.

REGISTER FOR COUPLE COUNSELLING | COVENT GARDEN
PERSONAL INFORMATION
Name *
Name
MEDICAL INFORMATION
MEDICAL AND PERSONAL HISTORY
DIFFICULTIES AND EXPECTATIONS
Please let us know about the nature of issue(s) you are contacting us about.
AVAILABILITY
To match you with the team member best suited to your specific needs, please tell us when you are available for counselling.
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
Please tell us who you would prefer to work with *
COUNSELLING AGREEMENT
We feel it is important that you are fully informed about the practicalities involved when using any of our services. The 'Counselling Agreement' below, outlines what to expect when coming for counselling and sets out the terms and the way we work. The agreement will be kept securely by Heart & Mind, but if you would like a copy for your own records please let us know.
CONSULTATIONS
1. When you agree to see a practitioner associated with Heart & Mind, you agree to see an independently working counsellor or therapist who offers their services within the agreed principles, values and fees of Heart & Mind. *
2. Consultations will give you the opportunity to address issues you would like to consider. The consultations may help you see things in new ways but ultimately you remain responsible for any decisions you make or actions you take *
3. A consultation will last 50 minutes each. We recommend that you do not come more than 2 or 3 minutes early for your appointment and please be aware that your session cannot be extended if you arrive late for any reason *
4. If you feel you don't benefit from your sessions we encourage you to discuss this with your counsellor. You can choose to discontinue counselling at any time. We will do our best to offer you an alternative source of help, either within the Heart & Mind network or make some suggestions as to where else you could go for support *
CONFIDENTIALITY
5. Counselling is a professional and confidential relationship between you and your counsellor. Your counsellor agrees to keep your information private unless you give them specific permission to disclose it. *
LIMITS TO CONFIDENTIALITY
6. Every counsellor is required by their profession to have regular supervision sessions during which they may discuss aspects of your therapy. However, your counsellor will make every effort not to reveal names or details which would identify you. *
7. There are limits to the security of online conversations (type written) and conversations via Skype. While your counsellor will not disclose any details or the nature of your conversations to others, there is currently no guarantee that someone else cannot access (hack) a copy of online or Skype conversations. *
8. If your personal counsellor comes to the conclusion that you or someone else may come to serious harm, they might advise you to contact your GP, Social Services etc. and if necessary, do so themselves. Also, there are some situations when a counsellor is legally required to report information. *
FEES & TERMS OF PAYMENTS
9. The initial consultation fee of £ 40.00 is non-refundable and payable within 24 hours after the initial appointment has been confirmed. The initial consultation fee is a reduced fee and valid for new clients only. Returning clients pay an initial consultation fee based on their annual gross income. *
10. To determine the fee you will be paying for any additional sessions you book, please indicate your personal annual income before taxes are taken off (income includes salary, retirement income, investment gains, bonuses etc). With no personal income, please use the gross annual income of your partner or family. *
11. You agree to pay for any additional sessions you book by setting up a direct debit mandate with Heart & Mind. Once set up, the consultation fee due will be debited from your account on the day of your appointment. *
12. If you need to change an appointment please give your counsellor as much notice as possible but at least 48 hours before your booked session. If you fail to attend, cancel or change an appointment at short notice (less than 48 hours' notice), you agree to pay the usual consultation fee. *
With your name and today's date you indicate that you understand and agree with the terms above *
With your name and today's date you indicate that you understand and agree with the terms above
Please tell us how you heard about Heart & Mind *
We agree to keep your information confidential unless there is a risk to your personal safety or the safety of a child or vulnerable adult. By using the registration form, you agree to Heart & Mind's 'Privacy and Data Protection Policy' and how we protect and use your submitted information. *

ANY QUESTIONS?

Find here the answers to some of the questions we are often asked


YOUR PRIVACY IS IMPORTANT TO US

To find out how we protect and use your information, read our 'Privacy and Data Protection Policy'