Give us a call
Open 7 days a week
71 Vyse Street, Jewellery Quarter, B18 6EX
Bereavement & Grief Counselling
Counselling for Domestic Violence
Eating Disorder Counselling
Counselling for low self-confidence
Counselling for low self-esteem
Counselling for OCD
Counselling for PTSD
Counselling for Self Harm
Counselling for Stress
Indian Head Massage
Past Life Regression
Reiki & Meditation
Attachment Based Psychotherapy
Cognitive Behavioural Therapy (CBT)
EFT – Emotional Freedom Technique
Eye Movement Desensitisation & Reprocessing (EMDR) Treatment
Humanistic Integrative Psychotherapy
Integrative Counselling & Psychotherapy Approach
Object Relations Therapy
Transactional Analysis (TA) Therapy
Please read this form before completing. We request this is completed 24 hours before your session, which allows us to prepare for your session however If you feel uncomfortable filling out this form - please fill out this alternative form instead:
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Date of birth
Address Line 2
ZIP / Postal Code
G.P. Phone number
Address Line 2
ZIP / Postal Code
Do you have a disability?
If so can you please describe how this affects your life and tell us if you have any special needs regarding psychotherapy.
Your issues. Please describe the nature of your difficulties, how long you have had them, how you think they began and how they affect your life at present.
In what ways do you hope that treatment such as, if appropriate, counselling or therapy could help you?
Have you ever sought help for emotional or psychological difficulties before?
If so, please give details: helped by GP, counselling or psychotherapy, referred to psychiatrist, hospitalised, etc.?
Has any other member of your family had help for psychological difficulties (please give details as far as you know them).
Trigger warning. Have you ever made a suicide attempt/suicidal thoughts or self harm?
If you've anwsered yes above, please could you give some details about when this occurred?
Are you on any medication at present for emotional/psychological difficulties, if so, please list these?
Is there any concern about your drinking or issues with non prescribed/prescribed drugs?
Have you ever had issues with eating?
Please give details below
Do you have any difficulties with your body? The way you feel about it and the way you think it looks?
Are you experiencing problems in relationships?
Coping: How do you cope with situations?
How easy do you find it to recognise your own thoughts?
List any things you can change to help yourself:
Is there anything you’ve tried which have worked for you?
Mother: Please describe your relationship.
Father: Please describe your relationship.
Siblings: Please describe your relationship(s).
What was the general atmosphere like at home, including how your parents got on with each other?
Were there any important changes, for example, moves or any other significant events, during childhood? Including any separations from the family or parental divorce. Please give approximate ages and details.
What was your experience of school like?
The terms and conditions and contract is specifically between the therapist carrying out the therapy and the client.
To view our terms & conditions,
I confirm I have read and agree with the terms & conditions on the link above and the information I have provided is accurate.