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Please complete the form below, then book your initial assessment by clicking the button at the bottom.


This helps us gather a little more information in advance to make your appointment as smooth and supportive as possible.

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Please note that some questions may cover sensitive or difficult topics.

Booking your Initial assessment

About You

This section helps us get to know you better and ensures we can contact you to book in for your Initial assessment.

Gender
Male
Female
Other
Date of birth
Day
Month
Year

GP Surgery

This helps us coordinate your care if and when needed to ensure your safety.

Next Of Kin

This is for in case we need to reach someone on your behalf.

Other Details

This section helps us gather information about your appointment preferences

Counsellor Preference
Male
Female
No Preference
Would you like to receive online counselling?
Yes
No
Maybe sometimes
If you'd like face-to-face support, what is the best location for you?

Please note that we do offer adult counselling sessions at our Children and Young People’s Centre if that is the most convenient location for you. We have suitable adult counselling spaces there to accommodate this.

Have you consider befriending services?
Yes
No
Maybe

A befriending service in mental health offers informal, one-to-one social support from trained volunteers. It’s designed to reduce loneliness, build confidence, and provide a listening ear for people who may be isolated or struggling emotionally. While not therapy, befriending can improve wellbeing by offering regular friendly contact, encouragement, and connection

Are you currently working?
Yes
No

Consent

Can we leave you voicemails
Yes
No
Can we send you texts?
Yes
No

Health and History

This information helps us understand the kind of support you need and allows us to tailor our services to best suit you. Please note that some questions in this section may cover sensitive or difficult topics.

Are you involved in any live or pending court proceedings?
No
yes
Are you involved with any other services?
No
Yes
Have you ever attempted self-harm?
Yes, recently
Yes, in the past
No, never
Have you ever attempted to take your own life?
Yes
No
Any suicidal thoughts at the moment
Yes
No
Do you currently have any plans to harm yourself or attempt suicide
Yes
No
It's complicated
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We do our best to match you with the right counsellor based on the information you provide. However, sometimes during sessions, it might become clear that your needs would be better supported by a counsellor with different experience or specialisms. If that happens, your counsellor will talk it through with you and explain the next steps to make sure you get the best support possible.

Please submit your form, then use the button below to book your appointment online.

If you prefer, you can also book by phone or email using the clickable contact details provided below.

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contact@citc.team

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0808 1963483 

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