Book Now - £45.00 Counselling Session with a Qualified Counsellor at Kilmarnock Station Counselling Service

What we offer

At Kilmarnock Station Counselling Service we are pleased to offer Cognitive Behaviour Therapy (CBT) and Person Centred Therapy. Both types of therapy are conducted on a 1 to 1 basis either face to face or online whichever suits your individual needs. Complete the brief details below and we'll call you to confirm your appointment.

Question Title

* 1. Do you require face to face or online sessions?

Face to face

Online

Question Title

* 2. which type of therapy are you looking for?

Cognitive Behaviour Therapy (CBT)

Person Centred Therapy

Question Title

* 3. Your full name

Question Title

* 4. Your contact phone number (mobile if possible since sometimes we text information about appointments

Question Title

* 5. Your email address (if you have one)

Question Title

* 6. Please tell us the name of your GP Surgery & Address

Question Title

* 7. Do we have consent your consent to contact your GP in an emergency

Yes

Question Title

* 8. The main issue I am looking for help with is:

grief

anxiety

social anxiety

self esteem

relationship issues

OCD

Anger

Other (please specify)

Question Title

* 9. Sorry to ask an intrusive questions but do you consider yourself to be a risk either to yourself or others at the current time?

Yes

Question Title

* 10. If you answered yes to the previous session please answer the following questions. Please read each statement below think how often you have felt that way in the last week, then mark the box which is closest to this.

	Not at all	Only occasionally	Sometimes	Often	Most or all of the time
I have thought of hurting myself	I have thought of hurting myself Not at all	I have thought of hurting myself Only occasionally	I have thought of hurting myself Sometimes	I have thought of hurting myself Often	I have thought of hurting myself Most or all of the time
I have made plans to end my life	I have made plans to end my life Not at all	I have made plans to end my life Only occasionally	I have made plans to end my life Sometimes	I have made plans to end my life Often	I have made plans to end my life Most or all of the time
I have thought it would be better if I were dead	I have thought it would be better if I were dead Not at all	I have thought it would be better if I were dead Only occasionally	I have thought it would be better if I were dead Sometimes	I have thought it would be better if I were dead Often	I have thought it would be better if I were dead Most or all of the time
I have been physically violent to others	I have been physically violent to others Not at all	I have been physically violent to others Only occasionally	I have been physically violent to others Sometimes	I have been physically violent to others Often	I have been physically violent to others Most or all of the time
I have threatened or intimidated another person	I have threatened or intimidated another person Not at all	I have threatened or intimidated another person Only occasionally	I have threatened or intimidated another person Sometimes	I have threatened or intimidated another person Often	I have threatened or intimidated another person Most or all of the time

Question Title

* 11. Can you tell us what slots you might be available for your chosen therapy? The wider your availability the more timely it is to allocate you to a counsellor. Please tick all that apply. Mornings are 9am-12pm Afternoons are 12pm- 5pm (last appointment is 4pm).

	Yes	No
Monday morning	Monday morning Yes	Monday morning No
Monday Afternoon	Monday Afternoon Yes	Monday Afternoon No
Tuesday Morning	Tuesday Morning Yes	Tuesday Morning No
Tuesday afternoon	Tuesday afternoon Yes	Tuesday afternoon No
Wednesday Morning	Wednesday Morning Yes	Wednesday Morning No
Wednesday afternoon	Wednesday afternoon Yes	Wednesday afternoon No
Thursday Morning	Thursday Morning Yes	Thursday Morning No
Thursday afternoon	Thursday afternoon Yes	Thursday afternoon No
Friday Morning	Friday Morning Yes	Friday Morning No
Friday Afternoon	Friday Afternoon Yes	Friday Afternoon No

What happens next
Appointment allocation is based on your availability and we aim to contact you with in 2 weeks of receiving your referral, once we have a therapist available.

Thank you for taking the time to complete this enquiry form.