Have you received counselling before?:
If yes, please indicate with which provider(s) below
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Please provide details about the counselling you have received in the past (length, dates, other
provider):
Are you currently receiving counselling from another organisation?:
If yes, please provide details*:
*
If you are receiving therapy from another counselling service, you can only start your sessions here if
that therapy has come to an end.
Have you ever been admitted to hospital experiencing mental distress?:
If yes, please give details:
Have you ever received a mental health diagnosis?:
If yes, what was the diagnosis:
Have you ever been prescribed medication to support your mental health?:
If yes, please give details:
Are you currently taking any medication to support your mental health?:
If yes, please give details:
Do you use, or do you have a history of using substances/alcohol?:
If yes, please give details:
Are you currently accessing any other services?
If so, please list which ones. For example, mental health, drug and alcohol, housing, employment support services, etc: