To match you with a suitable counsellor, please tell us your age.
18 - 25 years
26 - 35 years
36 - 45 years
46 - 59 years
60 years +
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.
If you wish to see a specific Heart & Mind team member please tell us the name of the counsellor / therapist
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. Please note: 'Counsellor and counselling' in this agreement will also refer to 'therapist and therapy'.
LIMITS TO CONFIDENTIALITY
Each subsequent consultation you book will be charged based on your gross annual income. To determine the fee you will be paying, 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