Initial Assessment Form for Counselling

This is the initial assessment application form if you would like to apply for counselling or play therapy for yourself or a child. The information you supply will be kept in the strictest confidentiality in line with BACP guidelines. 

The initial assessment will be over the telephone and will be free of charge.
Ongoing Session costs will be discussed during the initial assessment.

Initial Assessment Form


Section 1 : Applicant Information

Details of the parent, guardian or or professional making the application.

Section 2 : About The Child

Please note we will not be able to provide our services to children under 6 years old.

Section 3 : Overview Information

Please provide any background to why you are signing up for counselling, if you prefer to discuss this on the telephone, please just enter "To be discussed on the telephone" in the information box below.

Please note: This information is completely confidential and will not be shared with anyone unless there is an immediate risk of harm to yourself or others or to prevent a crime or act of terrorism.

Section 4 : Confirmation

Please use your mouse or finger to sign your usual signature.

Yorkshire Children’s Trust – a local charity, helping local children