Self Referral Form

Welcome

To arrange your first appointment, please fill out the below form of contact information and consent. When you submit this to us, we will add your name to our waiting list. You will be offered a first appointment as soon as we can arrange it. At this appointment, a counsellor will explore with you what your needs are and whether our services are right for you.
 
The full cost of each session is €60 however Cork Counselling Services operates a sliding scale so as to make the service available to all. A lack of money should never stop you from coming to counselling with us.
 
If a child or adolescent below 18 years is coming for counselling, we require that the first appointment be with the parents / guardians.
 
We have a long history of keeping client records safe. By signing this form, you understand that your personal data will be collected before and during counselling sessions. You understand that every effort will be made to keep your personal data safe and that it will only be used in line with our Data Protection and Privacy Policy
 
Finally, in protecting your privacy as a client we are unable to see other people with whom you have a close relationship while you are attending our service.

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Name
Address
Date Of Birth
Can we leave voicemail for you if we dont reach you by phone?
Can we contact you by email?
Do you have trouble climbing stairs?
Would you like a reminder text for your initial appointment?
Where did you hear about us?
Clear Signature
By signing I consent to the conditions outlined above and I apply for an initial appointment for myself with Cork Counselling Services

Where ordinary
people can make
an extraordinary
difference.

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