COUNSELLING REQUEST FOR ADULTS (AGE 16+) Order Number Your details First name * Last name * Date of birth * Ethnicity Gender * Phone number * Email address * Referral Source - who referred you or recommended counselling with me? * Reasons for counselling / personal background * Information about Counselling I acknowledge that the counselling I will receive is with Ana van Elswijk, a Mind Health Intern who is a trainee counsellor doing their placement at LifeSwitch Church. * Yes No I understand that everything I share will be held in the strictest of confidence, the only exception being if there is potential harm to myself or harm to others. In that case, the counsellor will work with me to decide the next steps * Yes No I will give as much notice as possible if I am unable to attend my counselling appointment. This is so the counsellor can offer the appointment to another client. Please text/ phone Ana (027 385 1694) or email ana@mindhealth.org * Yes No I understand that if I have any concerns about the counselling process, in the first instance I should talk to the counsellor. If the issue is not resolved I should contact the Placement Liaison Person, Hazel Prickett - phone 021 0354 990. Email hazel@mindhealth.org * Yes No
