To register for individual Low-Cost Counselling at our Covent Garden venue, please complete the application 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.

PERSONAL INFORMATION
Name *
Name
MEDICAL INFORMATION
MEDICAL AND PERSONAL HISTORY
DIFFICULTIES AND EXPECTATIONS
YOUR PREFERENCE
Please tell us who you would prefer to work with *
YOUR AVAILABILITY
What sites would you be available *
Please tell us when you are available
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
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
When you agree to see a practitioner associated with Heart & Mind, you agree to see an independently working counsellor who offers their services within the agreed principles, values and fees of Heart & Mind. *
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 *
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 *
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. *
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
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
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. *
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. *
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
Places for our 'Low-Cost Counselling Service' are subject to availability. If offered a low-cost counselling place, consultations will be charged at £ 25.00 each and are limited to a maximum of 12 sessions. *
To be considered for low-cost counselling sessions, please tell us which one applies to you. *
You agree to pay for any sessions 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. *
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'