This confidential questionnaire is protected by SSL (Secure Socket Layer). If you already feel that working online or via the telephone is a possibility for you, the questionnaire will enable me to learn a little more about you and help us decide if you have come to the right person.

Your Name (required)

Your Email (required)

Date of Birth


In a sentence or two please tell me a bit about why you are seeking support right now

Please tell me if you have any previous experience of Counselling, Psychotherapy or Psychiatric Evaluation

Have you taken or are you taking any medication? eg. antidepressants or anti-anxiety; if so, what?

Are you currently working on your issues with anyone else? If so, with whom?

Have you ever self harmed, harmed anyone else or thought about doing so ( including suicidal thoughts)? Please give details.

Any other comments

This New Client Questionnaire and any further intake assessment, together with any other communication or information given throughout the course of our work will be held in the strictest confidence.  Your right to privacy will be respected at all times.  Further details relating to confidentiality will be given before work commences.

Rhona Petticrew  Reg. MBACP (Snr. Accred. )

01691 587458


Call Rhona today for a confidential initial assessment, free of charge and with no obligation to continue.