New Client Questionnaire

The information you submit via this form is encrypted by Hushmail and will be seen only by UK Online Counselling

Your name

Date of Birth

Email address

Very briefly, what brings you to contact a counsellor at this present time in your life?

Please briefly describe any negative feelings or symptoms you may be experiencing, ie. feeling anxious, depressed, lonely, sad, angry, frustrated, etc?

Are you currently taking any medication such as anti-depressants or anti-anxiety? If yes please give details (otherwise state "No")

If you are actively suicidal it may be that online counselling is not the most suitable service for your needs, as it does not provide an emergency service. We can however explore this together upon my reply to your form submission, so please don't feel you need to hold back with your answers about this. It will have no negative bearing on us working together and you will not be judged for it.

Please say briefly why/when you felt suicidal and if something stopped you

Please use this field for any additional comments or questions you may have:

Rest Assured - Your Privacy
By submitting this form you are not subscribing or committing to anything. The information you provide will remain confidential and will be used only by me, Monica Sala (MSc) and only for the purpose of assessing your circumstances with a view to providing counselling. In the event that you decide not to proceed with online counselling for any reason, the details provided in your form submission will be automatically and permanently deleted from my records.

I am over 18 years of age

Under 18? click here

Your information will be encrypted.

Monica Sala (MSc)

UKCP Accredited Integrative Psychotherapist, UK Online Counselling

Trained at the Metanoia Institute, London and accredited by the United Kingdom Council for Psychotherapy (UKCP) in 2001. In practice for over 25 years, working in a number of face-to-face settings including private practice and NHS Primary Care surgeries. Member of the Association for Counselling & Therapy Online (ACTO)

ukonlinecounselling.com