Forms

Any information you provide will remain confidential.

Background Information Form

Please complete part 1 then click ‘continue’ to go to part 2

Background Information Part 1

Placeholder

Full Name

Address

Home phone

Mobile

E-mail

Age

Date of birth

Your G.P.

Medical history

Access

Previous counselling

Nature of the problem

Personal changes

How will counselling help?

Anything else?

Your availability

Male / Female Counsellor

How did you hear about the Oaks Counselling service?

You must submit part 1 before completing part 2 otherwise the information will be lost

Application Form for Fee Reduction

If you would like to apply for a reduction from our standard fee, we invite you to provide some further information, in confidence, about your circumstances and household income. This will enable us to decide on what fee arrangement we are initially able to offer you.

However, this arrangement may be limited both in terms of the amount and length of time.

Your counsellor might suggest the option of coming for sessions fortnightly, to help manage the costs. This works well for some people. Your counsellor will regularly review the cost of sessions with you

Application form for a reduction in fees

* Entry required to submit form

Name*

Phone*

E-mail

Your Income

Your spouse or partner's income (If applicable)

Expenses

Contribution

Other information

Oaks Counselling

An affordable counselling service for the Poole and Bournemouth area

Background Information Form

Background Information Part 1

Background Information Part 2

Please click on the following boxes which apply to you:

Application Form for Fee Reduction

Application form for a reduction in fees

* Entry required to submit form