Counselling Form This counselling form is to be completed before your first appointment. Name * First Name Last Name Email * Subject * Date of Birth MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Occupation Nationality Ethnic origin First language What is your availability for appointments? Preferred method of contact Email Telephone Have you attended counselling/therapy previously? Yes No What areas of your life would you like to work on in counselling? How long have you been concerned about the issue/s mentioned? What prompted you to seek support at this particular moment? What changes would you like to work on in counselling? What do you think your main challenge is to make these changes? What would you like to have achieved at the end of the therapy? Please make any other relevant comments here: Thank you!