REGISTER FOR COUPLE COUNSELLING | COVENT GARDEN
Name, address and phone number of your GP
MEDICAL AND PERSONAL HISTORY
Please let us know of any medication you are currently taking (if applicable).
Have you or anyone in your family ever been diagnosed with a mental health disorder (including eating disorders)? If yes, please explain.
Have you ever attempted suicide? If yes, please explain.
Are there any other medical concerns we should be aware of?
DIFFICULTIES AND EXPECTATIONS
What are your hopes and expectations of counselling?
Are you or have you ever been in therapy, counselling or coaching? If yes, please explain.
To match you with the team member best suited to your specific needs, please tell us when you are available for counselling.
Please tell us your age.
18 - 30 years
31 - 45 years
45 - 60 years
60 years +
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.
LIMITS TO CONFIDENTIALITY
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.
Income up to £ 25,000 = £ 40.00
£ 25,001 - £ 35,000 = £ 50.00
£ 35,001 - £ 45,000 = £ 60.00
£ 45,001 - £ 50,000 = £ 70.00
£ 50,001 - £ 55,000 = £ 80.00
£ 55,001 and above = £ 90.00
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