Enquiry for Counselling with Glasgow Counselling and CBT Centre Survey

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...

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

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 :-)