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    Application form for new clients

    This form should be filled in by the person who requires counselling. If you prefer we can fill in your form with you over the phone. Please phone us on 01923 239495 or 07444 768078

    If you feel your needs are high and you require an emergency assessment please contact us on one of the numbers above. Please be aware that Signpost does not currently have staff to answer your calls or emails on Fridays, Saturdays and Sundays. We will get back to you as soon as we receive your contact details and no later than 72 hours/3 days.

    If you require immediate help please contact the following services below or seek advice from your GP. If these are not options for you (it is a weekend and you can’t see your GP) go straight to A&E at your local hospital where you can be seen by the assessment team.

    * Required

    FemaleMalePrefer not to sayOther
    EmailMobileText

    WatfordHemel HempsteadBorehamwoodVideo counsellingTelephone counselling

    Morning 10-1Afternoon 1-4Evening 4-7

    Monday Monday Morning Monday Afternoon Monday Evening
    Tuesday Tuesday Morning Tuesday Afternoon Tuesday Evening
    Wednesday Wednesday Morning Wednesday Afternoon Wednesday Evening
    Thursday Thursday Morning Thursday Afternoon Thursday Evening
    Friday Friday Morning Friday Afternoon Friday Evening
    Saturday Saturday Morning Saturday Afternoon Saturday Evening
    FemaleMaleDon't mind
    Family or FriendGPSchoolCamhsReferred by other professionalOther

    Application form for new clients

    * Required

    Assessment and Issues

    Please mark all boxes which apply

    Abuse (emotional)Abuse (physical)Abuse (sexual)AddictionAnger/AggressionAnxietyASDADHDBereavementBullyingBehaviour problemsDepressionDrug or alcohol problemsEating disorderEducationFamily issuesFriendships/peer problemsGender identityMental Health issue (if not listed)Obsessional Compulsive Disorder (OCD)Panic attacksPersonality/Mood DisorderPhobiasRelationshipSelf esteem/confidenceSelf harmSexual identitySexual health/pregnancyStressSuicidal thinking/plansTraumaTrustWork/careerOther
    CounsellingCoachingDon't know (we can talk with you about this on the number shown at the top of this form)
    YesNo

    Application form for new clients

    * Required

    Monitoring

    All data will be stored responsibly and according to GDPR legislation and only for its intended purpose.

    NoneSensory impairmentLearning difficulties including dyslexiaPhysical disabilityMental healthOther
    Mother and FatherMother/Father onlyMother/Father and Step-ParentFoster parent(s)Adoptive Parent(s)Living aloneOther:
    BuddhistChristianHinduJewishMuslimSikhNonePrefer not to sayOther: