Counselling Application Form

This application form is for counselling (up to the maximum of 12 sessions) at the Herts Women’s Centre. We apologise for the amount of information required. However, the more information you can provide will help us in finding you the most suitable support.

If you would like help in filling in this form please contact us on 01438 742742.

All the information you provide will be held in strict confidence and is NOT shared with any third party.

About You:

Name:
Date of birth:
Address: / Postcode:
Home Tel No:
Mobile No:
Email:
Preferred method of contact: ………………………………………………………………………..

Is it OK to leave messages Yes No
Have you had Counselling before? Yes No

If Yes was this at the Women’s Centre? Yes No
When was this (approximate dates are fine) ……………………………………………………….

Did you find the Counselling helpful? Yes No
Have you also applied for Counselling elsewhere? Yes No

Your availability:

To get the best benefit from your Counselling it will mean that you will need to be available to attend the Centre once a week on an ongoing regular basis. Holidays / bank holidays will of course be taken into account and where possible your counsellor will try to make alternative arrangements for you.
Please take the time to consider any other regular commitments you may have and then tell us about your availability for your counselling sessions:
Please tick ALL the times you are available
9:30 - 12:30 (inc) 12:30 - 3:30pm (inc)

Tuesday a.m Wednesday p.m

Friday a.m Thursday p.m

Your Health:


Are you registered with a G.P? Yes No
Your G.P’s name: ……………………………………………………………………………………..
Name of your G.P Practice…
G.P’s Address: …………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
G.P’s Telephone Number: ………………………………………………………………………………

Are you taking any regular medication? Yes No
What is the name of your medication? ……………………………………………………………….
…………………………………………………………………………………………………………….
…………………………………………………………………………………………………………….
Have you had any contact with the Mental Health or Wellbeing Team?

Yes No
Do you have any other medical problems you would like us to be aware of?
Yes No
If Yes please tell us in your own words what they are:
…………………………………………………………………………………………………………….
…………………………………………………………………………………………………………….
Very briefly and in your own words please can you tell us about any difficulties you are experiencing and what it is you would like to discuss with your counsellor?
……………………………………………………………………………………………………………..
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Now please read and tick the 10 statements on page 4.
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………

Your Family:


Do you live on your own? Yes No
Do you live with a partner? Yes No

Do you have any children? Yes No
Please tell us the age and sex of each child;

………………………………………………… Boy Girl

………………………………………………… Boy Girl
……………………………………………….. Boy Girl
Please add more columns as necessary
Who is your next of kin:
Name………………………………………………………………………………………………………
Address……………………………………………………………………………………………………
……………………………………………………………………………………………………………..
Contact No………………………………………………………………………………………………..
Their relationship to you…………………………………………………………………………………

3. Counselling Fees:

The Herts Women’s Centre is a registered Charity. We are an independent organisation who relies on donations, small grants and regular supporters to pay our bills and run all of our services. Due to recent grant cuts, our counselling is no longer funded by grants or statutory services.

The only way we can continue to offer this service is to ask for a donation towards the costs. We try very hard to keep this affordable so that as many women can access the service as possible.

Listed below is a guideline of our fees. Kindly identify which category you are likely to meet and this will be discussed in more detail when we contact you with a first appointment.We can make individual payment arrangements of weekly or monthly in advance or the fee can be paid in full. Please note there will be a discount of £10 allocated to all full payments in advance.

Our counselling contract is 12 regular weekly sessions.

(Note the cost of Private Counselling varies and starts from a minimum of£45+ per session)

Fee for
12Sessions / Criteria / Please tick one box only
£120
(£10 per session) / This fee is charged for women in receipt of Income Support, Disability Living Allowance (DLA), Job Seeker’s Allowance (JSA), Employment and Support Allowance (ESA), State Pension or Universal Credit.
£180
(£15 per session) / This fee is charged for women who are on a low fixed income or in receipt of child/working tax credits or Universal Credit.
£240
(£20 per session) / This fee is charged for women working less than 25 hours per week.
£300
(£25 per session) / This fee is charged for women working part time but in excess of 25 hours per week.
£360
(£30 per session) / This fee is charged for women working full time on an income of less than £20,000 per year
£480
(£40 per session) / This fee is charged for women working full time with an income in excess of £20,000 per year.

What happens next?

Thank you for taking the time to complete this counselling application form. When we receive it, we will contact you to arrange an appointment and agree the fee for the contribution towards the cost of your counselling.

You will be offered the first available appointment to match the availabilityyou have identified so please let us know as soon as you can if your circumstances change or you no longer wish to be considered for counselling.

Please return this form marked Personal & Confidential to:

The Director

The Herts Women’s Centre

37-39 The Hyde

Shephall

Stevenage

SG2 9SB

Signed......

Date......

1