Counselling Self Referral | The Varis Medical Practice

Forres Health Centre Counselling Service Contract

This is a Counselling Service Contract with a Trainee Person Centred Psychotherapist
By completing and submitting the Self Referral Form below, you are agreeing to the terms of this Contract
Being Person Centred means that I am not here to give you any answers as such, but that I am here to help you work through things and hopefully find your own answers to things
I am regulated by COSCA, the professional body for Counselling & Psychotherapy in Scotland
Anything you tell me will be confidential, it will not be shared unless I feel that you or other people are at high risk. In that case I would discuss the issue with you before I pass information on to another person e.g. your GP
I will take very brief notes after the session in which you won’t be identified
The purpose of these notes is to jog my memory before I consult with you each time
I will also be discussing certain cases with my professional supervisor to ensure I am maintaining professional standards with my counselling
Each session will be up to 1hr long
There is no limitation to the number of times I can see you , we will review how we both feel things are going from time to time
If you Do Not Attend on two consecutive occasions you will however lose your place and need to complete another Self Referral Form

Forres Health Centre Counselling Service Self Referral Form

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Forres Health Centre Counselling Service Contract

• This is a Counselling Service Contract with a Trainee Person Centred Psychotherapist
• By completing and submitting the Self Referral Form below, you are agreeing to the terms of this Contract
• Being Person Centred means that I am not here to give you any answers as such, but that I am here to help you work through things and hopefully find your own answers to things
• I am regulated by COSCA, the professional body for Counselling & Psychotherapy in Scotland
• Anything you tell me will be confidential, it will not be shared unless I feel that you or other people are at high risk. In that case I would discuss the issue with you before I pass information on to another person e.g. your GP
• I will take very brief notes after the session in which you won’t be identified
• The purpose of these notes is to jog my memory before I consult with you each time
• I will also be discussing certain cases with my professional supervisor to ensure I am maintaining professional standards with my counselling
• Each session will be up to 1hr long
• There is no limitation to the number of times I can see you , we will review how we both feel things are going from time to time
• If you Do Not Attend on two consecutive occasions you will however lose your place and need to complete another Self Referral Form

Date Form Completed *

Full Name *

Age *

Email *

Brief description of your need for counselling *

Phone numbers we can contact you on about appointments: *

(Please note that we will not leave any messages. We will make 3 attempts to contact you. If we are unsuccessful, your referral will go to the end of the referral list. This is to ensure that no spaces are wasted / left empty because it is a high demand service.)

Checkboxes *

I have read and understood Forres Health Centre Counselling Service Contract

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