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* 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. Our aim is to get you into counselling within 4 weeks.

To continue, please complete the form below.

Your full name

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* 2. Date of Birth

Date

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* 3. What is your address?

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* 4. What is your email address

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* 5. What is the best telephone number to contact you on?

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* 6. What is your gender?

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* 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?

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* 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

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* 9. We can offer different formats of counselling, however in person sessions are limited and subject to availability. Please give a secondary option

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* 10. When are you usually available for counselling sessions?
(Please select all that apply)

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* 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.

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* 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?

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* 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.

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* 14. Name of your GP Surgery

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* 15. This project is available to anyone employed by a Wiltshire based organisation. You do not need to live in Wiltshire to access the service.

Please confirm the name of the Wiltshire based organisation you work for.

Please note we will not contact your employer

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* 16. 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?

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* 17. If you are happy to share your employer’s details, we can pass these on to Rethink so they can provide more information.

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* 18. 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.

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* 19. Relationship Status

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