aMAZE counselling therapy consultation form

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Discovering your unique way through your personal issue(s) begins here.

Your responses will be stored securely according to aMAZE counselling therapy Privacy Policy.

Please answer all of the questions to the best of your knowledge.

Email *

Full Name *

Address *

Preferred Contact Telephone Number *

Email *

Date of Birth *

YYYY

Relationship Status *

Single

Married

In a Relationship

Divorced

Widowed

Are you happy to be contacted by telephone?

Yes

Do you have a preferred time of contact via telephone?

Is it ok to leave a message?
*

Yes

Are you happy to be contacted by email?
*

Yes

Preferred method of contact:
*

Telephone

Required

Please state how you heard about aMAZE Counselling:
*

Please list any other service/support you are currently receiving:
*

G.P. Name:
*

G.P. Address *

G.P. Telephone *

Date of Last G.P. Visit (Estimation is fine)

Medication and reasons for taking:
*

Any disabilities including learning difficulties:
*

Emergency contact number, name & relationship:
*

Are you able to attend a regular appointment on a weekly basis?
*

Yes

If you can't make regular appointments please explain the reason: *

Is your current issue a long term or new issue?
*

What are the issues you'd like to work on through this process? Please be as specific as possible.
*

Do you have any previous experience of Personal Therapy/Counselling? If yes, please share something of your experience
*

Any dislikes and fears relevant to your issue? Any dislikes and fears about starting therapy?
*

Any religious views and practices you wish to share, or is relevant to our therapeutic relationship?
*

Thank you for your time completing this form.

Your first step towards your therapeutic journey has begun, and aMAZE counselling therapy will be in touch to organise your free 30 minute consultation.

Send me a copy of my responses.

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