Wiltshire Working Well Question Title * 1. Welcome to Help Counselling Services.In partnership with Wiltshire Council and Rethink, we are delivering a programme to support people living in Wiltshire (excluding Swindon) who are currently in work and experiencing mental health difficulties.This fully funded programme offers up to 8 confidential counselling sessions with a professional counsellor, focusing on a range of common issues.To continue, please complete the form below.Your full name Question Title * 2. Date of Birth Day/Month/Year Date Question Title * 3. What is your address? Line 1 Line 2 Town County Postcode Question Title * 4. What is your email address Question Title * 5. What is the best telephone number to contact you on? Question Title * 6. What is your gender? Male Female Non Binary Prefer not to say Question Title * 7. As counselling is offered for up to 8 sessions, we work together to focus on one or two key areas. From the list below, what would you most like support with during your sessions? Anxiety Low Mood Stress Bereavement & Loss Relationship Issues Question Title * 8. Because this is a short-term counselling service, there are some areas we are not able to support through this programme.We are unable to work with:• Trauma, PTSD or CPTSD• Addiction-related difficulties• Suicidal thoughts or self-harm• Longer-term or complex mental health difficulties, such as ongoing depression, bipolar disorder, emotionally unstable personality disorder (EUPD), psychosis, schizophrenia, or eating disorders Please confirm that you are not currently experiencing any of the above, or a similar level of difficulty. Question Title * 9. We can offer different formats of counselling. What is your preference Face to Face in Trowbridge Telephone Remote - Teams/WhatsApp/Zoom No Preference Question Title * 10. When are you usually available for counselling sessions?(Please select all that apply) Monday 8am to 12pm Monday 12pm to 5pm Monday 5pm to 9pm Tuesday 8am to 12pm Tuesday 12pm to 5pm Tuesday 5pm to 9pm Wednesday 8am to 12pm Wednesday 12pm to 5pm Wednesday 5pm to 9pm Thursday 8am to 12pm Thursday 12pm to 5pm Thursday 5pm to 9pm Friday 8am to 12pm Friday 12pm to 5pm Friday 5pm to 9pm Question Title * 11. We understand that counsellor gender and appointment times can be important. While we can’t always guarantee both, we will always do our best to take your preferences into account. Male Female No Preference Question Title * 12. Help Counselling Services is a small Wiltshire charity. We fundraise to support our work, and donations from clients help us to keep the service running. Any donation is entirely optional. Would you like to make a donation per session? No Yes £5 per session Yes £10 per session Yes £15 per session Yes £20 per session Yes One Off Donation at the End of Counselling Question Title * 13. As part of starting counselling, we ask for an emergency contact. This should be someone you trust, and who we could contact only in the event of a genuine health emergency. Name Contact Number Relationship Question Title * 14. Name of your GP Surgery Question Title * 15. We are working in partnership with Rethink to offer Mental Health First Aid training to employers. Do you think this is something your employer would be interested in? No Yes Question Title * 16. If you are happy to share your employer’s details, we can pass these on to Rethink so they can provide more information. Employer's Name Email Address Telephone Number Question Title * 17. What best describes your current employment status?We ask this to help us understand who is using our service and to improve access in the future. Full Time Part Time Shift Worker Sole Trader Self Employed Current Off Sick but Employed Question Title * 18. Relationship Status Married Co Habiting Civil Partnership Single Separated Divorced Widow Done
