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Enquiry Form for Face to Face and Video Counselling with Lanarkshire Counselling and CBT Centre

1.This enquiry form takes around 6 minutes to complete

Therapy Fees and Commitment
Before completing this referral form, please ensure you are happy with the session fees and are able to make the commitment.
We offer therapy sessions with a qualified therapist at £50 per session, or with a trainee therapist at a reduced rate of £20 per session. To help you get the most from your therapy, we kindly ask that you are able to commit to attending sessions over a period of 6 to 8 weeks.
Data Privacy Statement
The form 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 (eg: 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.How did you hear of our services?
2.Your name
3.Your address and postcode
4.Your date of birth
5.Your phone number (mobile if possible since sometimes we text information about appointments)
6.Your email address (if you have one)
7.How would you like us to make contact with you
8.What is the main issue you are seeking help for:
Main issue
Secondary issue
I dont think this applies to me
Not sure
Panic Attacks
Anxiety
Social
Anxiety
Low Mood/
Depression
Grief
Anger
Self-esteem
OCD
Phobia
PTSD diagnosis
Relationships
Couples Counselling £60
9.Have you had support through counselling before?
10.Are you on medication related to the issue you are seeking help for?
11.Do you have any contact with psychological/psychiatric services (eg CPN, or psychiatrist) or have you had in the past?
12.Do you consider yourself to be a risk to yourself and/or others at the current time?
13.Emergency Contact Details including GP
14.And now we would like to ask you about some of the options we offer

We offer two main choices in therapy.

1} Working with a qualified therapist at £50per session or, for most conditions however couples counselling is £60/session.

2} Working with a trainee at £20 per session for 8 sessions. Our trainees are highly skilled, studying on validated courses and receive supervision for their work with clients. They can work with mild/moderate presenting issues. It is NOT possible for trainees to work with higher risk conditions like PTSD, BPD, or for people who are at high risk of suicide. This will be subject to an assessment to determine working with a student would best support your needs.

If you feel unsure which option to choose give us a call to discuss on 01236 897544
15.When working with a therapist (trainee or qualified) we offer face to face or online therapy. Please select your preferred platform.
16.Can you tell us what slots you might be available for therapy sessions. Please tick all that apply.
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
17.Finally, we need some basic screening information to help us allocate your case. There are 10 statements. Please read each statement and think how often you have felt that way over the last week.
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
I have felt tense anxious or nervous
I have felt I have someone to turn to for support when needed
I have felt able to cope when things go wrong
Talking to people has felt too much for me
I have felt panic or terror
I made plans to end my life
I have had difficulty getting to sleep or staying asleep
I have felt despairing or hopeless
I have felt unhappy
Unwanted images have been distressing me
18.Is there anything else you think we should be aware of in relation to your enquiry for support?
Current Progress,
0 of 18 answered