Child & Family - Apply Online
Child & Family Counselling Form
Name (Parent or Guardian)
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Address
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Postcode
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Occupation
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Email
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Home Tel. Number
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Work Tel. Number
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Mobile
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Can we leave a message in confidence on any of the above? Please indicate by ticking box(es) below.
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Are Parental Rights / Legal Proceedings current or pending?
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Does any of those being referred know anyone in counselling with GCS or working for GCS?
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Please indicate your availability (time and venue) for weekly counselling)*
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*GCS does its best to allocate you to a counsellor within 4 - 6 weeks . If you are able to be flexible on times and days you could be available, then we would hope to allocate you within 2 - 4 weeks. These timescales may vary due to demand on the Service.
Do you have any planned breaks (i.e. holidays)? If so please give details:
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Name of person(s) being referred for counselling:
PERSON 1
Name
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Sex:
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Ethnic Origin
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Age/Date of Birth
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School/Occupation
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Disability/Special Needs
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Any relevant Medication being taken?
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GP’s name and address:
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PERSON 2
Name
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Sex:
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Ethnic Origin
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Age/Date of Birth
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School/Occupation
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Disability/Special Needs
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Any relevant Medication being taken?
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GP’s name and address:
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PERSON 3
Name
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Sex:
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Ethnic Origin
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Age/Date of Birth
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School/Occupation
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Disability/Special Needs
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Any relevant Medication being taken?
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GP’s name and address:
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PERSON 4
Name
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Sex:
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Ethnic Origin
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Age/Date of Birth
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School/Occupation
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Disability/Special Needs
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Any relevant Medication being taken?
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GP’s name and address:
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Name/Age/Occupation of other family members living in your home:
Family Member 1
Name
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Sex:
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Age/Date of Birth
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School/Occupation
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Family Member 2
Name
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Sex:
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Age/Date of Birth
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School/Occupation
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Family Member 3
Name
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Sex:
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Age/Date of Birth
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School/Occupation
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Family Member 4
Name
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Sex:
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Age/Date of Birth
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School/Occupation
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NON RESIDENT PARENT/S (in cases of separation)
Name
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Address
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Postcode
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Home Telephone
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Work Number
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Mobile
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Name and address of any other professionals involved with your family:
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How did you find out about the Service?
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ADDITIONAL INFORMATION
If you have anybody living in your home apart from those mentioned on the other sheet, please list below:
Name
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Age
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Relationship to family
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Has anybody recently left home? If yes, please specify:
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Has anyone recently come to live in the home? If yes, please specify:
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Have there been any deaths or loss in the family recently? If yes, please specify
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Please give a brief description of the present problem(s):
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Are you receiving help for this or any other problem from anyone else?
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Who wrote this account?
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Counselling Fees
Total Fee 0.00 GBP
Submit Application
BACP
British Psychoanalytic Council

GCS specialises in providing counselling and training of counsellors to professional standards. GCS was established in 1980 and has over 60 counsellors offering high quality affordable, counselling to the community of Gloucestershire in venues across the county including Stroud, Gloucester, Cheltenham, Tewkesbury and Cirencester. All our counsellors are supervised and managed within GCS and work within the BACP ethical framework. Some of our counsellors are counsellors in training; they work to the same standards as our qualified counsellors.

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