Couples Counselling Forms

If you are not attending couples counselling, then please fill out the individual counselling forms here

Form 1 - Couples Counselling Agreement

This form outlines the terms and expectations for Couples Counselling. It ensures that both partners are fully informed and comfortable with the structure, confidentiality and responsibilities of our work together.

Each individual attending couples therapy is required to complete both forms prior to the first session.

Client Details

First Name

Surname

Gender (Please specify or prefer not to say)

Preferred Pronouns:

Contact Number

Address

postcode

Email Address

GP Details

GP Name

GP Surgery Name & Address

Please describe any mental or physical health conditions and what brings you to counselling this time:

Emergency Contact Details

First Name

Surname

Relationship

Phone Number

Address

Postcode

Urgent support

Counselling is not an emergency service. If you are in crisis or need immediate support: • Call NHS 111, contact your GP or go to A&E • In an emergency, call 999

Confidentiality

Your privacy is important. I adhere to the GDPR and ethical standards of the British Association for Counselling and Psychotherapy (BACP). What you share stays confidential except in the following situations:

Risk of serious harm to yourself or others.
If I am legally required to share information, such as safeguarding concerns.
I discuss work anonymously in professional supervision.
In couples work, confidentiality applies to both individuals and couples. Individual sessions may be offered; if individual sessions occur, I will clarify whether any information shared will be brought into joint sessions. I do not keep secrets that may affect the integrity of our joint work, but I will always discuss this with you first.

Frequency and Duration of Counselling

Couples Therapy tends to last between 3 and 12 months. Sessions are either 60 or 90 minutes long, but you are free to leave whenever you want. We would normally meet weekly (60 minutes) or fortnightly (90 minutes). We will review the work we are doing in the sixth session, giving us both a chance to assess how the relationship is working out. It is advised that, for the first six sessions, we meet at least fortnightly. Any less frequently than this will impact our ability to develop an effective therapeutic relationship and for you to see any progress in our work together. When you choose to end counselling, please let me know in advance so we can work toward a planned ending and ensure you feel safe and supported.

Payment and Fees

The fee for each session must be paid in full to confirm the booking. Sessions are not reserved without payment and should be settled at the end of our session to secure the next appointment. Non-payment will result in the termination of our work together. Payment for each session is:

£50 for 50 minutes (Individual Session)
£70 for 60 minutes
£105 for 90 minutes
To reserve your slot, sessions can also be bought in blocks of four, £280 for 60-minute sessions or £420 for 90-minute sessions.
£130 for Walk and Talk Couples Therapy for 60 minutes

Bank Details

Name: Shafeen Mehdi (Business Account)
Account No: 59777743
Sort Code: 60-83-71

Cancellation and Lateness Policy

Please give at least 24 hours’ notice for cancellations, or the full fee will apply.
Missing two sessions without notice may result in your slot being offered to another client on the waiting list.
If you are late, the session will not be extended and will end at the scheduled time.

Limits for Counselling

Please do not attend counselling sessions under the influence of alcohol or drugs.

Counsellor acceptance

Your counsellor, Shafeen Farooq, accepts this Agreement and will provide counselling as described.

They will work to the BACP Ethical Framework and manage your information in line with GDPR and their Privacy Notice. This agreement is made under the laws of England and Wales.

Client declaration and electronic consent

I confirm that the information I have provided is true and complete to the best of my knowledge.
I confirm that I am the person named above and the sender of this form.
I consent to begin counselling under the terms set out in this agreement and to the processing of my personal data in line with the Privacy Notice.
I understand that ticking the box below and clicking Send constitutes my electronic signature and has the same effect as a handwritten signature.
The date, time and technical details of this submission are recorded for verification and all information sent and stored securely.

Client Consent and Agreement

I have read and understood the above information and agree to the conditions for counselling.

Name

Date of Sending

Client Acceptance

Tick to confirm agreement of the above

Form 2 - Couples Counselling Initial Intake Form

All information you record on this form, and everything you discuss with Mind and Souls Counselling will be kept in the strictest confidence in line with GDPR requirements. No information is shared.

This assessment is an important first step in your counselling. Please complete this form as fully and honestly as possible, so I can understand your needs and determine the best way to work together.

Please fill in individually

About you

First Name

Surname

Date of Birth

Phone Number

Do you give permission to set up a WhatsApp group with myself, you and your partner?

Yes No

Do you have children?

Do you work? If so, what do you do? Do you enjoy it?

Have you had therapy before? Either couples, family or individual.

Are you open to occasional individual sessions to support the couple’s work?

Are you on any medication to support your mental health? E.g. Anti-depressants/anxiety

Is there any history of neurodivergence (ADHD/Autism)/addiction/mental health disorders in your family?

Aims and objectives

What do you hope to accomplish through counselling?

What have you already done to deal with your relationship difficulties?

Your Relationship

What first attracted you to your partner?

What are your biggest strengths as a couple?

Do you feel that you or your partner has any issues with alcohol or substance usage?

Have either of you used physical violence towards the other? If so, please give details.

Have either of you considered/threatened separation or divorce?

Do you feel that either you or your partner has withdrawn from the relationship? How so?

How satisfied are you with your sexual relationship?

What is your current stress level in the relationship?

What is your current stress level overall?

What could you personally do to improve your relationship (regardless of what your partner does)?

What could your partner do to improve the relationship?

Please detail in order the top three concerns you have in your relationship.

Is there anything else you would like me to know about you?

Thank you for completing this assessment form. I value the time and thought you have put into your responses.