Client intake form

Please complete this before your first session. Share only what you are comfortable with.

Full name *

Preferred name

Date of birth *

Phone number *

Is it all right to leave a voicemail? * Yes No

Email address *

Is it all right to email you about appointments? * Yes No

Home address (optional)

Which would you like? * In person (£45, 50 minutes) Telephone (£35, 50 minutes)

Best days and times for you

Which counsellor would you prefer, if any? No preference Annabelle Alisha

In a few words, what would you like to talk about? (Optional. You can also tell your counsellor in the session.)

Have you had counselling before? * Yes No

Is there anything you would like us to know to make your sessions comfortable?

Are you currently seeing a GP, psychiatrist or other professional about your mental health? * Yes No

Are you taking any medication you would like your counsellor to know about? (Optional)

Do you feel safe at the moment? * Yes No Prefer to talk about it in session

Emergency contact: name, relationship and phone number

Is it all right for us to contact this person if we are seriously worried about your safety? * Yes No

Your GP's name and practice (only used with your separate written permission)

How did you hear about Aura?

Aura Counselling Partners

Individual counselling in Scunthorpe and surrounding areas, in person or by telephone. BACP registered counsellors.