Counselling Appointment Form :: Argyll Couple Counselling

I/we would like (choose one)

Individual Counselling

Couple Counselling

Your partner may always join later if they do not wish to participate to begin with.

My preferred method of counselling is (choose one but this can be changed at any time)

Face to Face (only in Oban)

Online

Telephone

I'm Not Sure Yet

My/our preferred time for appointments is

Daytime

Evening

Either

Your Details

Your Name *

Your Address & Postcode

Your Contact Phone number *

Your Email Address *

The source of your enquiry

Self

Ex (partner), Family Member or Friend

GP/Health Professional

Social Worker

Lawyer/Solicitor

Other

Please let us know here if you have any stipulations about how or when we may contact you, and if you have any particular requirements regarding the scheduling of your appointments.

Partner's Details

We will need your partner's details if you are requesting couple counselling.

Your Partner’s name

Your Partners Address if different

Your Partner's Contact phone number

Your Partner's E-mail address

Contributions Towards Counselling

We do not charge set fees but ask for a reasonable contribution towards the cost of your appointments. Contributions can always be reviewed later or discussed with your counsellor.

Please see our Client Contribution Guidance here.

Please tell us how much you will contribute for each appointment *

Payment Method

Gift Aid: I am a UK tax payer and wish Argyll Couple Counselling to claim Gift Aid on my contributions

If you are Experiencing Financial Hardship

We recognise that sometimes clients may experience difficulties in paying for their every-day routine expenditure. You will not be excluded from receiving help if you are struggling financially and cannot contribute what you would like.

I confirm that I am unable to contribute and wish to waive any contributions I may otherwise make

Yes

Monitoring

In line with Relationships Scotland’s National Policy, we are asked to collect simple “Before” and “Review” questionnaires. They are used anonymously to provide funders with qualitative and quantitative information on our counselling outcomes. We will e-mail them to you, and they can be filled in on-line and returned.

I/we confirm that we I/we will complete “Before” and “Review” questionnaires

Yes

Confidentiality

Please read our Confidentiality & Privacy Statement

I confirm that I agree to my data being held in accordance with the Confidentiality & Privacy Policy.

I agree

When couple counselling has been requested we will send a copy of the submitted form to your partner. We will also send them a copy of the Confidentiality & Privacy Statement for their agreement.

Already verified you are human.

Contact Us:
0300 111 0031