Individual Counselling Forms

Forms to complete

Before our first session, please complete both forms below.

If you are attending couples counselling, please click here to complete these forms instead.

Form 1 - Individual Counselling Agreement and Consent Form

This agreement sets out the responsibilities and expectations for both the counsellor and client. Our sessions aim to offer a safe and confidential space to explore personal issues and work towards positive change at your own pace. As your counsellor, I provide a non-judgmental, empathetic, and supportive service to help you address any concerns and challenges you wish to explore.

Session Format

Sessions last 50 minutes and are held via Google Meet or as Walk and Talk Therapy
Please ensure your phone is on silent. If you are expecting an urgent call, kindly inform me at the start of the session.

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 obliged to share information, such as safeguarding concerns.
I discuss work anonymously in professional supervision.

Session Frequency & Reviews

Weekly/fortnightly sessions are recommended for consistent progress, especially weekly for the first 6-10 weeks. We will review our work together regularly, including around session six.

Payment

Kindly pay in advance, at the end of our session to confirm your next slot.
Fees: £50 for online, £70 Walk and Talk Therapy sessions.
Couple Counselling online £70

Bank Details

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

Cancellation and Lateness

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.

Client Information and Consent

First Name

Surname

Date of Birth

Gender (Please specify or prefer not to say)

Preferred Pronouns:

Address

Postcode

Contact Number

Are you currently taking medication?

Yes No

If yes, please list your medication and any relevant details.

Please describe what brings you to counselling and any concerns or challenges you would like support with.

Emergency Contact

If under 18, provide parent/legal guardian details.

First Name

Surname

Relationship

Phone Number

Address

Postcode

GP Details

GP Name

GP Practice Name and Address

Please describe any mental or physical health conditions

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.

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 Submit 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.

If the client is under 18

If the client is under 18, a parent or legal guardian should sign on their behalf to confirm consent.

Name

Date of Sending

Client Consent / Agreement

Tick to confirm agreement of the above

Form 2

Individual Assessment Form

All information you record on this form, and everything you discuss with Mind and Soul Counselling will be kept in the strictest confidence in line with GDPR requirements. No information is shared. The only time I would share any information is if I became concerned that there was a serious risk of harm to you or to others. I will always discuss my concerns with you before making a disclosure.

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

The contents of this form will be discussed in more depth in our initial session together.

First Name

Surname

Date of Birth

Contact Number

Preferred method of communication

Main presenting issues

Any significant life events that you feel would be relevant to our work together? (Trauma, bereavement, DV, anxiety past trauma etc)

What do you hope to gain from counselling? What are you hoping to have achieved at the end of our work together?

What are your protective factors? What good things do you have in your life?

What do you do to relax? (E.g. hobbies, interests) How easy/manageable are these to achieve?

Do you work? If so, what do you do? Do you enjoy your job?

Please provide details of any prescription medication you are taking relevant to your mental health: (Please include any sleeping tablets/anti-depressants/anxiety medication)

Do you have any special needs, neurodivergence, accessibility issues or physical impairments that I need to be aware of? Any history of mental health in your family?

Have you had any thoughts about harming yourself in any way? Do you have previous history of self-harm/suicide attempts/suicidal thoughts?

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