1. Name.
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First Name
Last Name
3. Address.
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
4. Contact number.
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5. Email address.
*
6. Date of birth and gender.
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7. If you are attending as a couple please add your partner's name and make sure they also complete a form.
12. Will your partner be joining you in the sessions?
13. If you are in a relationship, does your partner/ know about your enquiry with us?
15. Do you have any children under 16 years? If so please say how many and what ages they are.
16. 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
17. What kind of counselling are you looking for?
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Please select one only. If you are not sure please call us on 0131 556 1527 for more information.
18. I would prefer sessions to be.
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Please select all that apply
19. Are you currently using any of our other counselling services?
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If yes, please give us a little more information.
20. Client payments per session - your annual household income.
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We are a charity and so ask all our clients to make a contribution to the cost of our services. The contributions cover our operational costs, enabling us to pay our professional staff a competitive rate and to support clients who need to pay a lower contribution. Below is a list of household income levels - this provides a guide to the amount we ask you to contribute and to confirm at your first appointment.
20a. Please tick if you are on benefits or allowances and we will discuss how much you can afford to pay
21. Where did you hear about Bright Light?
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Your answer helps us to raise awareness of our work. Please select all that apply.
a. Ability to deal with my difficulties
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b. Ability to deal with stress
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c. Feeling of being loved
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d. Managing anger and other strong emotions
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e. Coping at work
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f. Coping with children
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g. Coping with financial pressures
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h. Understanding of myself
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i. Ability to move forward
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j. Support your own wellbeing
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a. Communicate
b. Negotiate
c. Manage conflict
d. Manage financial pressure together
e. Express love
f. Understand each other
g. Feel about the future
h. Support each other's wellbeing
24. Please type your name below, as you would normally sign it and add the date of signing, Thank you.
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I have read and agree to the Bright Light Counselling Agreements and Contract for clients.
*
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.
Thank you for your enquiry.
A member of our ops team will be in touch to confirm your registration and discuss an initial meeting with you. We’ll aim to be in touch over the next few days but please bear in mind that during busy periods this can take slightly longer. In the meantime, if you need to speak to us we can be reached on 0131 556 1527 or by email.
Did you know for every £1 you give us we can claim an extra 25p of tax at no cost to you? You’ll find details here
