Individuals & Couples - Apply Online

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Counselling Registration Form
Full Name
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Date of Birth
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Age
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Gender
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Address
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Postcode
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Email
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Home Telephone
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Work Telephone
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Mobile Number
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Can we leave a message in confidence on any of the above? Please indicate by ticking box(es).
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How would you describe your ethnic origin?
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Occupation
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Do you have any disabilities and special needs?
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People (first names only) living in your home, how they are related to you and their age:
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Name and age of other people who are important but live elsewhere:
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Do you know anyone currently in counselling with GCS or working for GCS? If so, please give details.
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GP’s name and surgery:
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Please state medication you are currently taking relevant to your presenting problem:
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Please indicate your availability (time and venue) for weekly counselling.*
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Counselling is offered from 8AM to 8PM in Stroud, Gloucester and Cheltenham. Availability can be discussed at assessment.
Have you any planned breaks? (such as holidays)
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Counselling Fees (*)
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Please select whether you require individual or couples counselling. *Please note this includes a small fee to cover the Paypal cost.
Total Payment 0.00 GBP
   

CLINICAL
OUTCOMES in
ROUTINE
EVALUATION

IMPORTANT - PLEASE READ THIS FIRST

This form has 34 statements about how you have been OVER THE LAST WEEK.
Please read each statement and think how often you felt that way last week.
Then tick the box which is closest to this.

Over the last week

1. I have felt terribly alone and isolated
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2. I have felt tense, anxious or nervous
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3. I have felt I have someone to turn to for support when needed
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4. I have felt O.K. about myself
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5. I have felt totally lacking in energy and enthusiasm
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6. I have been physically violent to others
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7. I have felt able to cope when things go wrong
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8. I have been troubled by aches, pains or other physical problems
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9. I have thought of hurting myself
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10. Talking to people has felt too much for me
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11. Tension and anxiety have prevented me doing important things
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12. I have been happy with the things I have done
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13. I have been disturbed by unwanted thoughts and feelings
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14. I have felt like crying
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15. I have felt panic or terror
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16. I made plans to end my life
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17. I have felt overwhelmed by my problems
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18. I have had difficulty getting to sleep or staying asleep
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19. I have felt warmth or affection for someone
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20. My problems have been impossible to put to one side
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21. I have been able to do most things I needed to
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22. I have threatened or intimidated another person
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23. I have felt despairing or hopeless
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24. I have thought it would be better if I were dead
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25. I have felt criticised by other people
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26. I have thought I have no friends
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27. I have felt unhappy
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28. Unwanted images or memories have been distressing me
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29. I have been irritable when with other people
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30. I have thought I am to blame for my problems and difficulties
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31. I have felt optimistic about my future
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32. I have achieved the things I wanted to
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33. I have felt humiliated or shamed by other people
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34. I have hurt myself physically or taken dangerous risks with my health
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On submitting this application you will be taken to the PayPal website where you will be required to pay your counselling fees.

If you have any trouble submitting this form or making payment then please contact us and we will be happy to help you further.

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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