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9 Orme Court
London W2 4 RL
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Help Counselling
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Name
*
Phone number
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Date of Birth (DD/MM/YYYY)
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Gender
*
Email
*
Address Line 1
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Address Line 2
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Town
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County
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Post Code
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GP Practice Name
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GP Address line 1
GP Address line 2
GP Town
GP County
GP Postcode
GP Telephone Number
Have you ever been in the care of a Psychiatrist? If 'Yes' please provide detail of this care, if 'No' please state 'No'
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Have you ever had a formal Psychiatric Diagnosis from a Psychiatrist (not a GP)? If 'Yes' please provide details, if 'No' please state 'No'
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Why would you like to have counselling? What are the things you would like to talk about?
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Have you had any counselling or therapy before? If so, please give some details.
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Medication: please select any medication you might be taking for anxiety, depression or any other mental health diagnosis
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None
Anti-histamine
Citalopram
Clonazepam
Escitalopram
Lamotrigine
Mirtazapine
Olanzipan
Oxazepam
Paroxatine
Pregabolin
Prozac
Sertraline
Sulpiride
Venlafaxine
Other
If you selected 'other' in the medication section above, please list your medications here:
Availability - Sessions will take place with your Counsellor at the same time, on the same day each week. We are unable to reschedule sessions so please only provide availability for times you will be able to attend regularly.
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Monday AM From 10:00-12:00
Monday PM From 13:00-16:30
Monday Evening From 17:30-19:30
Tuesday AM From 10:00-12:00
Tuesday PM From 13:00-16:30
Tuesday Evening From 17:30-19:30
Wednesday AM From 10:00-12:00
Wednesday PM From 13:00-16:30
Wednesday Evening From 17:30-19:30
Thursday AM From 10:00-12:00
Thursday PM From 13:00-16:30
Thursday Evening From 17:30-20:30
Friday AM From 10:00-12:00
Friday PM From 13:00-16:30
Friday Evening From 17:30-19:30
Payment - We operate a two pricing system , if your household income is below £35,000 a year you can access the services for £25 per session. All assessments are charged at £25
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£25 per session
£40 per session
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