CONFIDENTIAL - COUNSELLING INTAKE FORM
Welcome to The Echo Society counselling service. Thank you for taking this step.
This form gives you space to tell us a little about what has been going on for you, your current circumstances and what you may be hoping for from counselling. This helps us understand your needs and consider the most suitable counselling support for you.
Where questions are optional, you may leave them unanswered or select ‘Prefer not to say’ where available. Please take your time and share what feels manageable.
Your information will be handled with care and confidentiality, in line with UK GDPR and our Privacy Notice.
If you need help completing the form, you’re welcome to contact our counselling team at counselling@theechosociety.org.uk.
Our counselling service is for ongoing therapeutic support and is not a crisis service. If you need urgent mental health support, please contact your GP or NHS 111. If you or someone else is in immediate danger, please call 999 or go to A&E.
1. GENERAL INFORMATION
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.
If you'd like to, please select your age range below (optional):
Is it okay for us to leave a voicemail or text message if needed?*
Current Relationship Status
2. EMERGENCY CONTACT
Please provide details of a person we can contact only in the event of a serious medical emergency or if we have significant concerns for your immediate safety.
How did you hear about our service?
Is anyone (e.g., solicitor, court, agency) advising or requiring you to seek counselling at this time?
4.YOUR CURRENT EXPERIENCES & EMOTIONAL WELLBEING
To help us understand your needs and provide appropriate support, please share your experiences in this area. All your responses are treated with care and confidentiality.
If you’d like to, please tick any areas that feel relevant right now:
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?*
Do you have any concerns that your phone, computer, or online activity may be monitored by another person?
If your circumstances change at any point and you have concerns about your privacy or safety during online sessions, please let your counsellor know so that we can discuss appropriate arrangements.
We understand that finding a private space for online counselling may sometimes be difficult. If this is a concern, we can discuss possible ways to support you in accessing sessions as privately and comfortably as possible.
6. HEALTH AND SOCIAL INFORMATION
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?
Are you currently receiving support from psychiatric, mental health, or other professional services?
Have you received any formal mental health diagnoses (e.g., depression, anxiety, PTSD)?
This includes diagnoses given by a GP, psychiatrist, or other mental health professional.
Are you currently taking any prescribed medication for your mental health?
Have you experienced suicidal thoughts or thoughts of self-harm?*
Are you currently receiving support from any crisis or emergency services?
Do you generally feel safe in your day-to-day life?
7. OCCUPATIONAL, FINANCIAL & LEGAL INFORMATION
What is your Employment Status?
Do you have financial concerns impacting your wellbeing?
Are you currently involved in any legal actions?
Are you seeking counselling primarily to obtain documentation or evidence for legal or court proceedings?
8. COUNSELLING HISTORY AND GOALS
Are you currently being treated by a counsellor or psychotherapist?*
Please note: Our counsellors and psychotherapists are not able to offer sessions if you are currently seeing another counsellor or psychotherapist, or are about to begin working with one. If this applies to you, please let us know — we’ll be happy to talk through next steps.
Have you previously had counselling/psychotherapy? *
To protect client privacy, to your knowledge, is anyone involved in the situation you’re seeking support for currently receiving or planning to receive counselling with The Echo Society?*
Have you ever been advised or asked by a professional, organisation, partner or family member to attend a behaviour-change, anger-management or similar programme?
Are you hoping for short-term counselling, long-term, or are you unsure at this stage?
Areas You May Wish to Explore (Optional)
If you’d like to, please tick any areas that feel relevant right now. This section is optional — you’re welcome to leave it blank if you’re unsure or prefer to decide later.
9. FEES AND AVAILABILITY
The Echo Society is a non-profit organisation committed to making counselling as accessible as possible. We operate a sliding scale fee structure, so your session fee is based on your annual income and appointment time. 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.
Ongoing Counselling Fees
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. If affordability is a concern, you're welcome to let us know during your assessment, and we’ll explore whether any appropriate options may be available.
Weekday Sessions (9am - 5pm)
Evening Sessions (5pm–8pm)
10. EQUALITY AND DIVERSITY MONITORING (VOLUNTARY)
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.
Ethnicity (Please select the option that best describes your ethnic group or background):
Religion or Belief (This information helps us understand the diverse needs of our clients.)
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).
11. DATA AND COMMUNICATIONS
How we use your data
We will use the information you provide to support your counselling pathway, including intake, allocation, safeguarding where necessary, and continuity of support.
Your information is handled in line with UK GDPR and our Privacy Notice.
Optional — Communication preferences
You’re welcome to skip this if you prefer.
Important information
You can change or withdraw your communication preferences at any time. This does not affect the counselling and support services you receive.
12. SIGNATURE
Thank you for sharing your information with us. We deeply appreciate your openness and trust. Our team is committed to supporting your well-being, and we look forward to walking alongside you.
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