Low Cost Counselling Self Referral | Ivy Light Therapy

Personal details

Start with your basic details and how we can identify your enquiry.

If you are applying on behalf of another person, use their details and information.

* Full name

* Age

* Date of birth

Marital status (optional)

* Address

* Email address

* Phone number

Employer/school name (optional)

Health and support information

This helps us understand your wider support situation and any relevant practical needs.

* Emergency contact name

* Emergency contact phone

* Are you registered with a GP?

* Do you have a disability?

If YES please enter name and address of your GP? (optional)

If YES please list any diagnoses you have with details: (optional)

* Are you currently taking or receiving any medication?

If YES please list medication and details: (optional)

Details of any other relevant professionals you are seeing now: (optional)

Do you have any special requirements? (optional)

Therapy history and current risk

These questions help us consider your background and whether any immediate safety concerns need to be taken into account.

* Have you had counselling previously?

If YES when did you have counselling and with who? (optional)

Do you drink alcohol? If YES, how much do you consume in a week? (optional)

Do you use recreational drugs? If YES, do you plan on continuing to take them? Please provide details: (optional)

Have you ever engaged in self-harming behaviours? If YES, please provide details, including the method and the date of the most recent occurrence: (optional)

Have you experienced suicidal thoughts? If YES, when was the most recent instance? (optional)

Have you ever made a suicide attempt? If YES, please provide details, including the method and the date of the attempt: (optional)

Current needs

Tell us what is bringing you to therapy and why the low cost service would be the most suitable option for you.

* What would you like to talk about during your sessions?

Any relevant family information? (optional)

* Please rate the severity of your problems or concerns on a scale of 1 to 10 with 10 being the most severe:

* What makes you eligible for our low-cost counselling service? Please provide a brief explanation of your current circumstances that make this service the most suitable option for you. This helps us ensure the low-cost service is reserved for those who need it most:

Is there any additional information you believe would be helpful for us to know? (optional)

Engagement and availability

Select at least one option in each section so we can understand how you are open to working with us and when you may be available.

Low cost counselling self-referral

Our self-referral form

Personal details

Health and support information

Therapy history and current risk

Current needs

Engagement and availability