Enquiry for Counselling with Glasgow Counselling and CBT Centre
This enquiry form takes around 4 minutes to complete
Data Privacy Statement
This form is to help us support your enquiry and help get the right support for you. It collects some personal information to allow us to follow up on your enquiry and to help us match you to the right therapist. Your data will be kept secure and only used for that purpose. It will be deleted from this electronic platform once you have been allocated to a therapist. We do use some of the information (e.g. age information and postcode) to understand our client base better but nothing in that use would compromise your privacy or identify you.
Continuing with this enquiry form will be considered confirmation that you have read and understood this data privacy statement.
Let's start with some basics
1.
Your name
2.
Your address
3.
Your date of birth
4.
Your phone number (mobile if possible since sometimes we text information about appointments)
5.
Your email address (if you have one)
6.
How would you like us to make contact with you?
Phone
Email
Either is fine by me
And now it would be great to know some more about what you are seeking help for...
7.
The main issue I am looking for help with is:
Main Issue
Secondary Issue
I don't think this applies to me
Not sure
Low mood
Main Issue
Secondary Issue
I don't think this applies to me
Not sure
Anxiety
Main Issue
Secondary Issue
I don't think this applies to me
Not sure
Social anxiety
Main Issue
Secondary Issue
I don't think this applies to me
Not sure
Panic attacks
Main Issue
Secondary Issue
I don't think this applies to me
Not sure
Relationship issues
Main Issue
Secondary Issue
I don't think this applies to me
Not sure
Anger
Main Issue
Secondary Issue
I don't think this applies to me
Not sure
Self-esteem
Main Issue
Secondary Issue
I don't think this applies to me
Not sure
OCD
Main Issue
Secondary Issue
I don't think this applies to me
Not sure
Phobia
Main Issue
Secondary Issue
I don't think this applies to me
Not sure
PTSD
Main Issue
Secondary Issue
I don't think this applies to me
Not sure
Grief
Main Issue
Secondary Issue
I don't think this applies to me
Not sure
Any other information that it would be helpful to know about what you are looking for help with?
8.
Have you had support through counselling before?
Yes
No
If yes, can you tell us a bit more
9.
Are you on medication related to the issue you are seeking help for?
Yes
No
If yes, it would be helpful to have the details.
10.
Do you have any contact with psychological/psychiatric services (e.g. CPN or psychiatric) of have you had in the past?
Yes - currently
Yes- recent past (contact within the last 2 years)
Yes - not recent past (more than 2 years since contact)
No
If yes, can you provide us with brief details
11.
Sorry to ask an intrusive question but do you consider yourself to be a risk to yourself and/or others at the current time?
Yes
No
If yes, please tell us some more
And now we would like to ask you about some of the options we offer
12.
Therapy at GCCC is £50 per session. We offer face-to-face and therapy from our centre on Buchanan St, Glasgow. We also offer therapy via video (usually Zoom) and phone. Can you tell us about your preferred platform for therapy:
Face-to-face
Video
Telephone
13.
Can you tell us what slots you might be available for therapy sessions bearing in mind that you will most therapy sessions take around 50-55 minutes. Please tick all that apply
Early morning (before 0930)
Morning
Afternoon
Evening
Monday
Early morning (before 0930)
Morning
Afternoon
Evening
Tuesday
Early morning (before 0930)
Morning
Afternoon
Evening
Wednesday
Early morning (before 0930)
Morning
Afternoon
Evening
Thursday
Early morning (before 0930)
Morning
Afternoon
Evening
Friday
Early morning (before 0930)
Morning
Afternoon
Evening
Saturday
Early morning (before 0930)
Morning
Afternoon
Evening
Sunday
Early morning (before 0930)
Morning
Afternoon
Evening
Any specific information we should be aware of about your availability?
14.
Is there anything else you think we should be aware of in relation to your enquiry for support?
Thank you
for taking the time to complete this enquiry form. We will process it and get in touch with you in the near future :-)