The Counselling Hubb

Enquiry Form

This enquiry form takes around 6 minutes to complete.

Data Privacy Statement
The information collected is used to provide you with appropriate therapy and healthcare services. To communicate with you regarding appointments, treatment plans, and other relevant information.
We implement a variety of security measures to maintain the safety of your personal information. Your data is stored in secure systems that are protected from unauthorised access. We regularly review our security practices to ensure the integrity and confidentiality of your information.
We do not sell, trade, or otherwise transfer your personal information to outside parties without your consent, except as necessary for the provision of healthcare services or as required by law.
You have the right to access your personal information and request corrections if it is inaccurate. Your data be deleted from this electronic platform once you have been allocated to therapist.
By completing our therapy intake form, you acknowledge that you have read and understood this Data Privacy Statement and agree to the collection, use, and protection of your personal information as described.
Thank you for trusting us with your personal information. Your privacy is our priority.
1.Your Name?(Required.)
2.Your Address and Postcode(Required.)
3.Your Date of Birth(Required.)
4.Please enter phone & email address.(Required.)
5.What is the main issue you are seeking help for?(Required.)
6.Are you on medication related to the issue you are seeking help for?(Required.)
7.Do you consider yourself to be a risk to yourself and/or others at the current time?(Required.)
8.Emergency Contact(Required.)
9.Finally, we need some basic screening information to help us allocate your case. There are 10 statements. Please read each statement and think how often you have felt that way over the last week.(Required.)
10.Is there anything else you think we should be aware of in relation to your enquiry for support?