CONFIDENTIAL - COUNSELLING INTAKE FORM

This form supports clinical assessment and safeguarding. You may skip any question you do not feel comfortable answering.

Welcome to The Echo Society counselling service. Thank you for taking this step — we understand it may not have been easy to reach out.

This form helps us build a gentle understanding of what’s been going on for you, so we can match you with the right support.

Please feel free to take your time as you go through it.

Your information will be kept confidential and handled in line with UK GDPR. It is stored securely using systems that meet UK GDPR and HIPAA‑grade security standards, and accessed only by our clinical team to support your counselling pathway.

If you need any support completing the form, you’re welcome to email our counselling team at: counselling@theechosociety.org.uk.

If you are currently in immediate danger or need urgent support, please contact emergency services or a crisis service such as Samaritans (116 123) before continuing.

1. GENERAL INFORMATION

Full Name

Preferred Name (if different)

Date of Birth

Age Eligibility: *

I am 18 years old or over.

Please note: We are only able to offer counselling to UK residents due to the complexities of different rules and regulations regarding licensing, insurance, training, and qualifications of counsellors and psychotherapists across different countries.

Phone

Address — Street Address, Town/City, Postcode

Is it okay for us to leave a voicemail or text message if needed?

Current Relationship Status *

2. EMERGENCY CONTACT

Emergency Contact (strongly encouraged for safeguarding)

We ask for an emergency contact so we can act quickly in the rare event of a serious safety concern or medical emergency. If you don’t have someone you feel able to list right now, you’re welcome to enter “Not available”.

Name:

Phone Number:

Relationship to you:

If you feel comfortable, you’re welcome to provide your GP’s name and contact details. This helps us follow safeguarding guidelines. We would aim to discuss this with you first, unless there are serious concerns about your immediate safety.

3. REFERRAL INFORMATION

How did you hear about our service?

4. EXPERIENCES WITH NARCISSISTIC ABUSE / COERCIVE CONTROL

Some of the next questions are more personal. You’re welcome to move through them at your own pace and skip any questions you prefer not to answer.

You do not need to interpret or label your experiences — only share what feels relevant to you.

To help us understand your needs and provide appropriate support, please share your experiences in this area.

All your responses are treated with the utmost confidentiality.

If you’re completing this form in a situation where someone else might see your device or online activity, you’re welcome to use a private device or return to the form at another time.

Have you experienced narcissistic abuse or coercive control?

If Yes, please let us know how distressing the impact feels for you at the moment.

Other – please specify:

Are you and the perpetrator/s currently living in the same home?

Yes

Are you and/or your children currently in a safe place?

Yes

Unsure

Prefer not to say

5. SAFE SPACE FOR ONLINE COUNSELLING SESSIONS

Do you have a private and safe space for all your online assessment and counselling sessions, where you won't be overheard or interrupted?

If No, please describe the situation, and if you have any initial thoughts on how we might support you to find a safe space, please share them:

Is there anything that would help you feel more comfortable, safe, or supported during online sessions? You’re welcome to keep this brief or skip if you prefer. (For example: pacing, check‑ins, structure, or anything else.)

We understand that finding a private space may be a challenge. We've got strategies and resources to help, and will work with you to explore solutions that prioritise your privacy and safety.

6. HEALTH AND SOCIAL INFORMATION

Some of the next questions are a bit more detailed. You’re welcome to keep your answers brief or skip anything that doesn’t feel comfortable right now.

To ensure we can provide effective counselling/psychotherapy, please provide the following health and social information. This helps your counsellor/psychotherapist understand your overall well-being and any specific needs.

How is your physical health at present?

Do you have any children or other dependents?

Yes

If Yes, please list their ages (e.g., 5, 12, adult dependent):

Are you currently receiving psychiatric services, professional or any other support services?

If yes, when were you treated and for what reasons?

Have you ever been given a mental health diagnosis? You’re welcome to skip this question if you prefer.

If yes, you’re welcome to share any diagnoses or anything you feel is important for your counsellor to know. (Optional)

Are you currently taking any prescribed medication for your mental health? You’re welcome to skip this if you prefer.

If Yes, please list any medication(s) you’re currently taking

Have you experienced suicidal thoughts?

Yes

Prefer not to say

If you are currently in immediate danger, please contact emergency services or a crisis support service such as Samaritans (116 123).

This form is not monitored in real time and should not be used for urgent support.

If you feel comfortable, please share any dates or context that might help us understand your experience.

Do you have any ongoing physical symptoms or health concerns? (e.g., chronic pain, headaches, hypertension, diabetes)

None

7. OCCUPATIONAL, FINANCIAL & LEGAL INFORMATION

What is your current employment situation? You’re welcome to skip this question if you prefer.

If “Other”, you may share a brief description if you’d like. (Optional)

Do you have financial concerns? You’re welcome to skip this question if you prefer.

If yes, you’re welcome to share any brief context that feels important. (Optional)

Are you currently involved in any legal actions? You’re welcome to skip this question if you prefer.

If yes, you’re welcome to share any brief context you feel comfortable disclosing. We can’t offer legal advice, but we may be able to signpost helpful resources. (Optional)

8. COUNSELLING HISTORY AND GOALS

Are you currently being treated by a counsellor or psychotherapist? You’re welcome to skip this question if you prefer.

If yes, you’re welcome to share anything you feel is important. (Optional)

If you are currently working with another counsellor or psychotherapist, or are about to begin, please let us know. We can talk this through with you and consider what feels most appropriate together.

Have you previously had counselling or psychotherapy? You’re welcome to skip this question if you prefer.

If yes, you’re welcome to share type, length, or anything that feels relevant. (Optional)

If you’ve had counselling before, was anything that felt particularly helpful or unhelpful? You’re welcome to keep this brief or skip if you prefer.

Please describe any other support systems you currently have (e.g., family, friends, community groups, spiritual support, other professionals). If 'Other' applies, please specify details here:

You’re welcome to keep this brief — whatever feels most important right now.

Please describe your current situation or circumstances for which counselling is being sought.

Are you hoping for short-term counselling, long-term, or are you unsure at this stage?

What are your hopes for counselling, or what would you like to explore or change?

You’re welcome to keep this brief — anything you feel is useful is completely fine.

When you imagine counselling, what would feel most supportive for you at this stage?

A gentle, slower‑paced space to explore

A more structured, goal‑focused approach

A mix of both

I’m not sure yet

Is there anything else you’d like your counsellor to know?

8B. Areas for Specific Exploration (Optional)

To help us understand your needs and guide your sessions, please check any of the following areas you would like to explore in counselling. This section is optional — you’re welcome to leave it blank if you’re unsure or prefer to decide later.

Life Transitions & Personal Growth

Navigating major life changes (e.g., career, relocation, parenthood, retirement)

Overwhelm / Feeling stuck

Work-life balance

Financial Concerns (impact on well-being)

Self-Care / Preventing Burnout / Compassion Fatigue

Personal Growth & Recovery

Identity, Meaning & Self‑Understanding

Personal Development / Self-Discovery

Finding Purpose / Meaning in Life / Finding Joy

Reclaiming Identity

Highly Sensitive Person (HSP) aspects

Gentle, Recovery‑Oriented Experiences

Reconnecting with what feels meaningful or nourishing to you

Finding moments of safety, calm, or steadiness

Being kinder or more understanding toward yourself

Listening to your own voice, instincts, or feelings

Exploring what supportive connection or belonging might feel like for you

Building emotional support in ways that feel right for you

9. FEES AND AVAILABILITY

The Echo Society is a non-profit organisation committed to making counselling accessible to everyone. We operate a sliding scale fee structure, so your session fee is based on your annual income. This approach helps us provide affordable support to all, while ensuring our services remain sustainable. Our aim is for you to focus on your emotional well-being without financial concerns.

Initial Assessment Fee

The first session (around 50 minutes) has a one-time fee of £45, paid directly to your counsellor.

Ongoing Counselling Fees

Ongoing sessions are paid directly to your counsellor on a sliding scale.

Please select one option that best reflects your situation and aligns with your income band where possible. This helps us offer fair, accessible counselling while sustaining reduced‑rate spaces for those who need them.

Reduced Rate (Supported Access) Reduced‑rate spaces are currently unavailable.

--- Weekday Sessions (9am - 5pm) ---

Evening Sessions (5pm–8pm) Evening sessions are currently unavailable. We will explore suitable weekday options with you.

Prefer not to say / Unsure (We can discuss this during your initial assessment session.)

AVAILABILITY: *

10. EQUALITY AND DIVERSITY MONITORING (VOLUNTARY)

This section is completely optional. You’re welcome to skip any or all questions.

We are committed to providing an inclusive and accessible service to all. Gathering this information helps us monitor the diversity of our client base and ensure our service is meeting the needs of all communities. This section is voluntary, and your responses will not affect the service you receive. This information will be kept separate from your clinical notes and used for statistical monitoring only.

Sexual Orientation:

Prefer to self-describe (please specify):

Ethnicity (Please select the option that best describes your ethnic group or background):

If you'd like to, please specify your ethnic background (e.g., English, White and Black Caribbean, Indian, African, etc.):

Religion or Belief (This information helps us understand the diverse needs of our clients.)

If your belief is not listed, please specify:

Do you identify as disabled or neurodivergent?

(This information helps us ensure our service is accessible and to identify any reasonable adjustments you may require. Examples include physical disabilities (e.g., mobility, sensory impairments), long-term health conditions (e.g., chronic pain, diabetes), learning differences (e.g., dyslexia, dyspraxia), or neurodevelopmental conditions (e.g., ADHD, Autism Spectrum Disorder).

Yes

If yes, please let us know the nature of the condition and any adjustments that would help you access our service.

11. DATA AND COMMUNICATIONS

How we use your data

We will process your personal data, including sensitive information, so that The Echo Society can provide counselling and support services. This is done in line with UK GDPR and our Privacy Policy, under Article 6(1)(b) and Article 9(2)(h). This information is provided for transparency and does not require any action from you.

Optional — Communication preferences

You’re welcome to skip this if you prefer.

I agree that The Echo Society may contact me regarding my counselling (for example, scheduling, updates, or urgent communications), primarily via email and in line with my stated contact preferences.

Important information

You can change or withdraw your communication preferences at any time. This does not affect the lawful basis used to provide counselling and support services.

12. SIGNATURE

Thank you for sharing this information with us. We appreciate your openness, and we look forward to supporting you.

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13. OPTIONAL FEEDBACK

We value your experience. Please share any thoughts or feedback on completing this form.