START

Thank you for your interest in the Centre for Better Health’s counselling service. Please note that this is a self-referral form and must be completed by the individual applying for counselling.

Before starting your application, please read and agree to the statements below.

I understand that I may be required to attend an assessment as part of my application.

I understand that the Centre will review my application and assess whether or not the service can meet my needs.

If I am offered counselling, I will be offered a weekly session on a day and time that matches the availability I indicate in this application. If I am unable to accept this, I will only be offered one other session, after which point my application will be closed.

This is a face-to-face service and I must be able to attend my sessions in person.

I understand that the Centre will not offer counselling to counselling students who are seeking therapy solely to fulfil their course requirements, and cannot provide written confirmation of attendance in this circumstance.

If you are a counselling student, and are seeking therapy for reasons outside of your course requirements, please tell us where you are studying:
To ensure there is no conflict of interest please let us know the name of anyone you know who is accessing or working at the service:
I have read and agree to the Counselling Service Client Guidelines :

Please note that if the primary reason you are seeking counselling is to address adoption issues, an eating disorder, substance misuse or bereavement we advise you to contact a specialist counselling service. For more information, write to us at counselling@centreforbetterhealth.org.uk

PERSONAL DETAILS



Date of birth (please enter as DD/MM/YYYY):


Gender:


Gender Self-Description:


Employment Status:


Current Address



Borough:
If you are from outside of London, please indicate where from below:



Can we leave a voicemail?:



EMERGENCY CONTACT

Please provide the details of a person to contact in case of emergency. This can be someone who is supporting you through another service, or a friend or family member. Please ensure that the emergency contact is someone who is often available

Emergency contact:


Emergency contact relation to you:


Emergency contact phone number:


We require all individuals applying to this service to be registered with a GP surgery. Please provide your surgery details below.

GP Surgery Name:


GP Surgery Address:


Please confirm that this information has been provided:

SELF ASSESSMENT - Part One

Please briefly describe your current mental health and wellbeing, the issues you wish to address in counselling and any other information you feel we need to know. We understand that it may be hard to share this. Your response is confidential and will help us to assess your application.
Please indicate which of the below you are experiencing currently:

Aggression:
Anxiety:
Bereavement:
Depression:
Domestic Problems:

Multiple Factors (please explain below):

Emotional Difficulties:
Panic Attacks:
Post Traumatic Stress Disorder:
Relationship Problems:
Stress:

Other (please explain below):



Have you received counselling before?:
If yes, please indicate with which provider(s) below

To select multiple options:
For Windows: Hold down the control (ctrl)+ select
For Mac: Hold down the command button


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:


SELF ASSESSMENT - Part Two

How have you been feeling over the last week?

To help us to better understand your thoughts, feelings and activities over the last week, we ask that you also complete a short self-report measure called the ReQoL (Recovering Quality of Life), together with some additional questions.

Please complete the form by clicking on the link here*.

Please note that we will not be able to proceed with your application without this information

*The form will take you about 5 minutes to complete.

AVAILABILITY

Your counselling will be on the same day and at the same time each week. If your availability changes whilst you are waiting for an appointment, you must contact the centre to inform us.
We ask you to do this to help us reduce waiting times and to deliver our services as efficiently as possible.
Please tick here to indicate that you have read and understood this statement:
Please mark all of your availability in the section below. The more options you give us, the quicker we will be able to allocate you to a counsellor.
Morning sessions are 9am, 10am, 11am,12pm
Afternoon sessions are 1pm, 2pm,3pm,4pm
Evening sessions are 5pm, 6pm, 7pm (Tuesday, Wednesday and Thursday only)

Answer either YES or NO to each option
Monday Afternoon:

Tuesday Morning:
Tuesday Afternoon:
Tuesday Evening:

Wednesday Morning:
Wednesday Afternoon:
Wednesday Evening :

Thursday Morning:
Thursday Afternoon:
Thursday Evening :

Friday Morning:
Friday Afternoon:

Please state any exceptions to the availability selected above:

FEE

Fees:
All evening sessions are charged at £40. We operate a sliding fee scale for our daytime counselling sessions based on your income. Please read this document and select which fee applies to you.

Counselling Fees:
If you have selected one of our concession rates, please email your proof of circumstances to: counselling@centreforbetterhealth.org.uk

DIVERSITY MONITORING

We are committed to ensuring that the clients and volunteers we work with reflect the diversity of our community, and that barriers that prevent underrepresented groups from accessing our services are gradually identified and removed. To help us to do this, we encourage you to answer the below questions.

How did you hear about our service?:


Ethnicity:


Ethnic Category - Other:


Religion or Belief:


Other Religion or Belief:


Sexual Orientation:


Other Sexual Orientation:


Housing Status:


Other Housing Status:


Relationship Status:

First Language Please note that our counsellors practice in English:

Experience of criminal justice system:


END

Inclusion

Please note that access to the Better Health Hub is via a small flight of stairs.

Do you have any disability, audio or visual impairment, mobility issues or any other support needs?


If yes, please give details, including any reasonable adjustments you may require. :


Data Protection

The Centre for Better Health needs to collect this data about you in order to establish if we can provide you with an appropriate service. We will use the information that you have provided in accordance with the Data Protection Act 2018. You can read our Privacy Notice for information on how we handle this data.

Please type your name below to confirm that you agree to your data being stored and processed by the Centre for Better Health.


City and Hackney Wellbeing Network

If you live in the City of London or London Borough of Hackney, you may be eligible to join the City and Hackney Wellbeing Network. As a member of the Network, you could access courses and groups at the Centre for Better Health, free of cost to you.

I would like to be contacted by email about joining the City and Hackney Wellbeing Network:


To submit your application click "SUBMIT"