/Bright Light

1. Name. *

First Name

Last Name

3. Address. *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

9. Are you paying for your counselling sessions and claiming the costs from your employer? *

If yes, we will contact you to discuss your payment contribution.

Yes

No

14. Will your partner be joining you in the sessions?

Yes

No

15. If you are in a relationship, does your partner/ know about your enquiry with us?

Yes

No

18. How well do you think your children are coping with the current family situation?

Please indicate on a scale of 1 to 5 where 1 is very poorly and 5 is very well

1 very poorly

2

3

4

5 very well

not applicable

19. What kind of counselling are you looking for? *

Please select one only. If you are not sure please call us on 0131 556 1527 for more information.

Couples

Individual

Not sure

20. I would prefer sessions to be. *

Please select all that apply

Online

Face-to face

By phone

21. Are you currently using any of our other counselling services? *

Yes

No

If you are unable to afford £30 per session each week, we can offer fortnightly sessions to help spread the cost. Please tick the box if you would like to discuss this.

Yes, I would like to discuss further

22. Where did you hear about Bright Light? *

Your answer helps us to raise awareness of our work. Please select all that apply.

A friend or family member

My employer

Searched online

Social media

Relationships Scotland

Another agency or charity

Your GP

A solicitor

a. Ability to deal with my difficulties *

1 very poor

2

3

4

5 very good

not applicable

b. Ability to deal with stress *

1 very poor

2

3

4

5 very good

not applicable

c. Feeling of being loved *

1 very poor

2

3

4

5 very good

not applicable

d. Managing anger and other strong emotions *

1 very poor

2

3

4

5 very good

not applicable

e. Coping at work *

1 very poor

2

3

4

5 very good

not applicable

f. Coping with children *

1 very poor

2

3

4

5 very good

not applicable

g. Coping with financial pressures *

1 very poor

2

3

4

5 very good

not applicable

h. Understanding of myself *

1 very poor

2

3

4

5 very good

not applicable

i. Ability to move forward *

1 very poor

2

3

4

5 very good

not applicable

j. Support your own wellbeing *

1 very poor

2

3

4

5 very good

not applicable

a. Communicate

1 very poorly

2

3

4

5 very well

not applicable

b. Negotiate

1 very poorly

2

3

4

5 very well

not applicable

c. Manage conflict

1 very poorly

2

3

4

5 very well

not applicable

d. Manage financial pressure together

1 very poorly

2

3

4

5 very well

not applicable

e. Express love

1 very poorly

2

3

4

5 very well

not applicable

f. Understand each other

1 very poorly

2

3

4

5 very well

not applicable

g. Feel about the future

1 very poorly

2

3

4

5 very well

not applicable

h. Support each other's wellbeing

1 very poorly

2

3

4

5 very well

not applicable

I have read and agree to the Bright Light Counselling Agreements and Contract for clients. *

I agree

Gift Aid

Gift Aid allows us to claim an extra 25p on every £1 you contribute towards your counselling contributions. All you need to do is make a Gift Aid declaration by agreeing to let us reclaim the tax from HMRC. For example if you contribute £40 Gift Aid will increase that to £50 at no extra cost to you. I am a UK taxpayer and would like Bright Light to reclaim the tax on my contributions or donations. I understand that if I pay less Income Tax and/or Capital Gains tax than the amount of Gift Aid claimed on all my donations in that tax year then it is my responsibility to pay any difference. You can opt out of Gift Aid at any time by giving us a call.

I agree