First Name *

Last Name *

Email *

Number

Brierfly Tell Me About What Brings You To Counselling. *

1. Are you over 18? *

• Yes
• No

2. Have you been feeling suicidal/attempted suicide in the last 6 months? *

• Yes
• No

3. Have you attempted self-harm or had thought of self-harming in the past 6 months? *

• Yes
• No

4. Have you been experiencing any issues with reality testing: that is, are you able to objectively evaluate your own feelings and thoughts against external reality? *

• Yes
• No

5. Have you been diagnosed/suffering from psychosis in the recent months? *

• Yes
• No

6. Are you generally familiar and comfortable with using computers, smartphones and the like? *

• Yes
• No

7. Have you got sufficient hearing to manage video conferencing? *

• Yes
• No

8. Have you got a sole access to a computer, tablet, smartphone or a laptop with a camera and headset that is password-protected and has an up-to-date anti-virus protection and a secure Wi-Fi? *

• Yes
• No

9. Have you got access to a quiet room where you can talk without being overheard or interrupted during your online counselling session? *

• Yes
• No

10. Are you able and willing to provide your GP and an emergency contact details (this is a standard procedure in counselling professions and required for emergency/safeguarding purposes)? *

• Yes
• No

Declaration: I declare that the answers provided were answered to my best knowledge and are correct. *

• Yes
• No

I understand that by supplying incorrect information my suitability for online counselling services may be affected and my safety concerned with the therapeutic process could be compromised. *

• Yes
• No

Name

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