Before your first session

A peaceful woodland path beside a gentle stream in soft morning light

Starting therapy is a meaningful step, and I want us to make the most of our time together from the very beginning.
This short form helps me understand a little about you before we meet: your background, what's brought you here, and a few practical details like emergency contacts and how I handle confidentiality.
It takes most people around 10 to 15 minutes to complete. There are no right or wrong answers, and if anything feels unclear or you'd rather talk through a section in person, that's completely fine.

There are two short forms on this page. Please complete both before we meet, one after the other.
Lynn Walker, NCPS Accredited Counsellor

Please answer as openly as you feel comfortable. Your responses are confidential and will be handled with care.

A few more details before we meet

This is the second of the two forms on this page. It covers your health, how you are doing right now, and the agreements for working together. Please allow about 15 minutes.

Answer as openly as you feel able. If something is hard to put in writing, leave it blank and we can talk it through in our first session.

Full name (as on your first form)

Email address (as on your first form)

About you

Preferred name and pronouns

Date of birth

Month

Day

Year

Home address

Postcode

Preferred contact method

Is it all right to leave a voicemail?

Yes

Emergency contact and GP

Your first form has your emergency contact's name. Please add how they are related to you and their phone number.

Emergency contact: relationship to you and phone number

GP name and surgery

GP surgery phone number

GP surgery address

Your health and wellbeing

Prescribed medication (please include dose and who prescribes it, if you can)

Alcohol, nicotine or recreational drug use

Physical health conditions or sensory needs I should know about

Any previous counselling or therapy, and what helped or did not

What brings you to counselling

What would you like from our work together?

Any phobias or triggers I should be aware of

Your strengths and what helps you cope

A brief summary of your concerns

Keeping you safe

I ask these questions so I can look after you well. If your answers suggest you are at risk, I will talk with you about what would help. This form is not a crisis service and may not be read straight away. In an emergency, call 999, go to A&E, or call Samaritans on 116 123 at any time.

Do you have thoughts of harming yourself or ending your life at the moment?

Sometimes

Yes, often or right now

If you would like to say more about this, please do

Any history of self-harm or suicide attempts

What helps you stay safe when things feel very hard

Any legal orders or Social Services involvement I should know about

Online sessions

Our sessions are held over Zoom. These two answers let me act quickly if the connection drops or I am worried about you.

Where will you usually be at the start of each video call? (address or place)

A back-up phone number to reach you if the call drops

If you are under 16

Only complete this section if you are under 16. A parent or guardian needs to give consent.

Parent or guardian full name

Parent or guardian phone number or email

I am the parent or guardian and I consent to this young person having counselling. (Under 16s only)

How I look after your information

I collect this information so I can offer counselling safely and keep the records my profession requires. I handle it under UK GDPR and the Data Protection Act 2018.

Your answers are held in Wix, where this form is stored, and in my own secure storage. Client records are kept for 7 years.

You can ask me for a copy of the information I hold about you, or ask me to correct it, at any time by contacting me directly.

Agreements

Please tick each box to show you have read and agree.

Crisis protocol: I understand this practice is not a crisis service. In an emergency I will contact 999, go to A&E, or call Samaritans on 116 123.

Attendance and cancellation: I understand sessions are 60 minutes. If I arrive late, the session will be shorter and is charged at the full rate. If I cancel within 24 hours of a session I will be charged half the session fee. If I cancel within 4 hours I will be charged the full fee.

Fees, communication and ending therapy: I understand fees are reviewed once a year in April, with two months' notice of any change. Phone and email are for arranging sessions only, not for therapeutic support, and I will not send friend or follow requests on social media. When we end therapy, 2 closing sessions are recommended, and my file is closed after 3 consecutive weeks of no contact.

Data and privacy: I have read how my information is looked after and I consent to it being stored and used as described.

I give permission for Lynn to contact my GP if she is seriously concerned about my safety. She will talk to me about it first where she can. (Optional)

I am happy to receive occasional practice updates by email. (Optional)

How you found me

How did you hear about me?

Declaration

Typing my full name below and adding today's date is my signature. I confirm the information I have given is true to the best of my knowledge.

Type your full name

Today's date

Month

Day

Year