Road Traffic Accident Questionaire

The Self-Referral

Aspirations?

Multi-select

Reduce negative feeling and thoughts

Explore broad set of issues

Reduce or remove addictions

Establish and maintain relationships

Remove or reduce negative cycles

Other

What Would You Like Help With?

Multi-Select Available

Addictions

Anger

Anxiety

Body Dysmorphia

Chronic Fatigue Syndrome

Chronic Pain

Depression

Dissociative Disorders

Health Anxiety

Fibromyalgia

OCD

Continued

Psychosis

Panic Disorder

Personality Disorder

Phobias

PTSD

Social Anxiety

Stress

Suicidal Thought

Self-Harm Thoughts

Other

Address & Contact

Your Name?

PostCode?

Date of birth?

You would like?

NHS Application

NHS Application’s rate of success depends on your location. The standard timescales are 8 weeks from when your GP sends our application to the funding panel.

Pay Privately & NHS Application

Paying privately allows you to start counselling quickly. When this form is completed, we will arrange your counselling.

Fees
Introduction Session £50
Pay-as-you-go £70
Saver3 (3 sessions) £180

NHS Application’s rate of success depends on your location. The standard timescales are eight weeks from when your GP sends our application to the funding panel.

Pay Privately

Paying privately allows you to start counselling quickly. When this form is completed, we will arrange your counselling.

Fees
Introduction Session £50
Pay-as-you-go £70
Saver3 (3 sessions) £180

GP Details

Surgery Name

Postcode

Dr Name (if Known)

Home?

Relationship?

Single

Divorced

Live-In-Partner

Married

Children?

Yes

No

Employment?

Employed?

Yes

No

Status

Full-Time

Part-Time

Are You Medically or Physically Able to Work?

Yes

No

Other

Are You Retired?

Yes

No

Are you a student?

Yes

No