Counselling Referral Form - Wellspring Therapy & Training

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Wellspring Therapy & Training

Counselling, Therapy and Training in Harrogate, North Yorkshire

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If you are aged 19 or older you can refer yourself for counselling using the form below. The form asks questions to help us assign you the right counsellor by understanding your needs and circumstances. If you are 18 or under please use our Youth Counselling referral form.

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About you
Name*
First Last
Address*
Address 1 Address 2 City Postcode
Date of birth*

Day
Month
Year
Age*
Gender*
What is your preferred pronoun?
Phone number*
Is it OK to leave a voicemail message on your phone?*
- Yes
- No
Email address*
How did you hear about us?*

Availability and finance
When are you available to attend counselling?
(Tick all that apply)
Monday
- Morning
- Afternoon
- Evening
Tuesday
- Morning
- Afternoon
- Evening
Wednesday
- Morning
- Afternoon
- Evening
Thursday
- Morning
- Afternoon
- Evening
Friday
- Morning
- Afternoon
- Evening
Counselling sessions usually take place at Wellspring House, however if you have a confidential space, we may be able to offer counselling via video or telephone call. To indicate your availability please tick all that apply:*
- Face to face counselling
- Video call counselling
- Telephone counselling
Donations*
As a charity, Wellspring seeks to provide professional, affordable counselling, but to ensure our service is sustainable we rely on your contributions. The more you are able to contribute, the more you will be helping us to continue to offer our services to adults and young people who cannot afford private counselling. Please select the amount that is affordable for you to pay weekly.

We do not want finance to be a barrier to anyone accessing the support they need. If you have concerns about paying the minimum amount for your weekly sessions we would be happy to call you to talk about an affordable payment. Please select this option if you would like us to do this.
- £45: If you are able to contribute £45 for your weekly sessions you qualify for our Associate Counsellor Service. You will be seen as soon as possible by one of our associate counsellors. You are not jumping the queue and people on our affordable waiting list are not waiting longer, as all associate counselling slots are offered in addition by counsellors.
- £40
- £35
- £30
- £25
- £20
- £15
- Please contact me: Either I am unable to pay the minimum amount, due to being on income related benefits or I have a payment agreement with Wellspring through my employer or other organisation.
Please provide details:*

Counselling
Please note all information given here is confidential and used only for allocation to an appropriate counsellor.
What issues would you like to bring to counselling?*
How do you hope counselling will help?*
Please answer the following questions about yourself in the last week.
I have felt able to cope when things go wrong:*
- Yes
- Sometimes
- No
I have felt I have someone to turn to for support:*
- Yes
- Sometimes
- No
I have hurt myself or taken dangerous risks:*
- Yes
- Sometimes
- No
Please give as much detail as you think would be helpful.*
I have threatened or intimidated someone:*
- Yes
- Sometimes
- No
Please give as much detail as you think would be helpful.*
Have you ever experienced any of the following?*
Tick all that apply
- Eating disorder
- Feeling suicidal
- Attempted suicide
- Self-harm
- Emotional abuse
- Violence
- Addiction
- Physical abuse
- Sexual abuse
- None of the above
Please give as much detail as you think would be helpful.*
Are you applying to Wellspring because you want to see a Christian counsellor?
- Yes
- No
If you have a preference for a male/female counsellor, you can specify this here.
(please be aware that this may affect your waiting time for an appointment)
Would you be open to seeing an art therapist?
- Yes
- No
Have you had counselling before?
- Yes
- No
How long ago, who with, and for roughly how long?
Who knows you are coming for counselling?

Work and family
Employment details
Please select all that apply to you.
- Full time
- Part time
- Unemployed
- Resigned
- Made redundant
- Sick leave
- Other
More details:*
Nature of your present or last work:
Family information
Please select all that apply to you.
- Single
- Married
- Widowed
- Separated
- Divorced
- Remarried
- Living together
Do you have children?
- Yes
- No
Please give genders and ages:
What words best describe the atmosphere in the home you grew up in?
Are you adopted, or do you want to explore issues relating to adoption?*
- Yes
- No
Medical and/or psychiatric history
GP name, practice and phone number:*
Please give details of past or current medical problems and/or mental health diagnosis:
Are you taking any medication currently?*
- Yes
- No
Please list your current medication:*
Are there any professionals involved in your care?*
For example: a social worker / a carer / a prevention team worker / drugs worker
- Yes
- No
Which service(s)?*
Are you under the care of NHS Mental Health Services?*
- Yes
- No
Which service(s)?*
Do you see a Link Worker or someone from the Community Mental Health Team?*
- Yes
- No
Is their support due to end within 6 weeks or has it recently ended?*
- Yes
- No
Do you have a Care Coordinator or a Care Plan?*
- Yes
- No
Do you see a psychologist/psychiatrist?*
- Yes
- No
Are you on any waiting list for support?*
- Yes
- No
Which services?*
Wellspring has one ground floor counselling room, do you have any specific needs regarding accessibility?
- Yes
- No
What accessibility requirements do you have?
Is there anything else you'd like to tell us?
Consent*
I understand that Wellspring will only use the information I share with them for purposes of providing a counselling service. I consent to my information being used, stored, retained and destroyed in accordance with the General Data Protection Regulation (GDPR).
- I understand and agree
If you would like to know more about how we look after your data please see our privacy notice.
Name
This field is for validation purposes and should be left unchanged.

A: Wellspring House
78 High Street, Starbeck
Harrogate, HG2 7LW
T: 01423 881 881
E: office@wellspringtherapy.co.uk

Opening times
Monday 9am - 8.30pm
Tuesday 9am - 8.30pm
Wednesday 9am - 8.30pm
Thursday 9am - 8.30pm
Friday Varies, please call
Saturday & Sunday - Closed

We work to the British Association for Counselling and Psychotherapy (BACP) Ethical Framework for Good Practice and the Association of Christian Counsellors (ACC) Code of Ethics.
We are a Registered Charity number 1100420 and a Company limited by guarantee Number 4728609.
Wellspring is an Affiliated Organisation number AT 326 of the Association of Christian Counsellors (ACC).

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