KSRHT Form

KSRHT Form
What type of therapy are you looking for?
Do we have your permission to contact GP surgery in an emergency?

Contact Details

The main issue I am looking for help with is:

Please select only one issue for each row. It is not possible for a trainee therapist to work with higher risk conditions such as PTSD or with people who are at higher risk of suicide.
Main issue
Secondary issue
What option are you looking for?
It’s not possible for a trainee therapist to work with higher risk conditions such as PTSD or for people who are at risk of suicide.
Have you had support through counselling before?
Are you on medication related to the issue you are seeking help for?
Do you have any contact with psychological/psychiatric services (eg CPN, psychologist or psychiatrist) or have you had in the past?
Sorry to ask an intrusive question but do you consider yourself to be a risk either to yourself or others at the current time?

If you have answered yes to the previous question please answer the following question. Please read each statement below and think how often you have felt like that way in the last week, then mark the box which is closest to this.
I have thought of hurting myself
I have made plans to end my life
I have thought it would be better if i were dead
I have been physically violent to others
I have threatened or intimidated another person
I have hurt myself or taken dangerous risks with my life
Can you tell us what slots you might be available for your chosen therapy? The wider your availability the more timely we will be able to allocate you a counsellor. Please tick all that apply.
Mornings are 9am – 12pm, Afternoons are 12pm – 5pm (last appointment time is 4pm)
Where did you hear about our services?

More Info

First session time
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