Other information
OK to leave a message?
-- select -- Yes No
Area living in/nearest town
-- select -- Maidenhead Slough Windsor
Date of birth
Ethnicity
-- select -- Asian: Bangladeshi Asian: Indian Asian: Pakistani Asian: Any other background Black or Black British: African Black or Black British: Caribbean Black or Black British: Any other background Chinese Mixed: White and Asian Mixed: White and Black African Mixed: White and Black Caribbean Mixed: Any other background White: British White: Irish White: Any other background Any other ethnic group Prefer not to say
Gender
-- select -- Female (including trans woman) Male (including trans man) Non-binary Other Prefer not to say
GP Practice
-- select -- 240 Wexham Road Abbey Medical Centre Ascot Medical Centre B & A Ccg Extended Hours Service Bharani Medical Centre Bhft (Bracknell) Bhft (Slough) Binfield Surgery Boundary House Surgery Bracknell Pct Ent Clinic Bracknell Urgent Care Centre Wic Burma Hill Practice Burnham Health Centre Camhs - Bracknell/M221001 Chapel Medical Centre Chapel Row Surgery Chatham Street Surgery Cippenham Medical Centre Circuit Lane Surgery Claremont Holyport Surgery Clarence Medical Centre Cookham Medical Centre Cordwallis Road Surgery Crosby House Surgery Crown Wood Medical Centre Crown Wood Medical Centre Datchet Health Centre Desborough Surgery Dr Nabi Easthampstead Surgery Evergreen Practice Farnham Dene Med Practice Farnham Road Practice Finchampstead Practice Forest Health Group Great Hollands Practice Green Meadows Surgery Grove Medical Centre Grovelands Medical Centre Herschel Medical Centre Holyport Surgery Iver Medical Centre Kings Corner Surgery Knowle Green Medical Kumar Medical Centre Langley Health Centre Lee House Surgery Linden Medical Centre Magnolia House Surgery Manor Park Medical Centre Milman & Kennet Surgery New Hope New Wokingham Road Surgery Park House Surgery Parkside Practice Pembroke Surgery Priory Avenue Surgery Ragstone Road Surgery Redwood House Surgery Ringmead Medical Practice Rosemead Surgery Ross Road Medical Centre Runnymede Medical Practice Russell Street Surgery Sheet Street Surgery Shinfield Medical Practice Shreeji Medical Centre Slough Extended Hours Service Slough Wic Solutions 4 Health South Meadow Surgery Southmead Surgery Swallowfield Medical Practice The Avenue Medical Centre The Cedars Surgery The Doctors House, Marlow Medical Group The Gainsborough Practice The Orchard Surgery The Sandhurst Group Practice The Symons Medical Centre The Village Medical Centre The Waterfield Practice Threeways Surgery Tilehurst Surgery Partnership Tilehurst Village Surgery Twyford Surgery University Medical Group Virginia Water Medical Practice Wargrave Practice Westcall Ooh Westwood Road Surgery Wexham Road Surgery Wokingham Hub Wokingham Medical Centre Woodlands Park Surgery Woodley Practice Woosehill Practice Unknown
Diagnosed mental health condition
-- select -- Yes No
Diagnosed Details
Your availability
When are you available to have counselling with us? Please let us know which days and which times of the day that are most convenient for you.
Please choose as many options as you think would be helpful. We will do our best to accommodate this
Preferred Location
-- select -- Maidenhead Slough Windsor Burnham Online
How did you hear about us
-- select -- GP Internet Search Word of mouth Social Services School CAMHS CMHT Talking Therapies Mind Other Agency
What is the main reason you are seeking counselling with us?
-- select -- Depression Anxiety Bereavement Issues with drugs/alcohol/gambling Behaviour Issues (Including Anger) Family and Relationship Issues Post-traumatic stress disorder Eating disorders Personality disorders Self harm Suicidal Thoughts Sexuality/Gender Self-care (including low self-esteem) Abuse ADHD Autism Obsessive compulsive disorder Bi polar disorder Phobias
The next questions ask about your current mental health. Please answer each question below about how you have been feeling in the last two weeks
Little interest or pleasure in doing things
-- select -- Not at all Several Days More than half of the days Nearly every day
Feeling down, depressed or hopeless
-- select -- Not at all Several Days More than half of the days Nearly every day
Trouble falling asleep or sleeping too much
-- select -- Not at all Several Days More than half of the days Nearly every day
Feeling tired or having little energy
-- select -- Not at all Several Days More than half of the days Nearly every day
Poor appetite or over eating
-- select -- Not at all Several Days More than half of the days Nearly every day
Feeling bad about yourself or that you have let yourself or your family down
-- select -- Not at all Several Days More than half of the days Nearly every day
Trouble concentrating on anything, such as reading a book or watching television
-- select -- Not at all Several Days More than half of the days Nearly every day
Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety that you have been moving around a lot more than usual
-- select -- Not at all Several Days More than half the day Nearly every day
Thoughts that you would be better off dead or hurting yourself.
-- select -- Not at all Several Days More than half of the days Nearly every day
Feeling nervous, anxious or on edge
-- select -- Not at all Several Days More than half of the days Nearly every day
Not being able to stop or control worrying
-- select -- Several Days Not at all More than half of the days Nearly every day
Worrying too much about different things
-- select -- Not at all Several Days More than half of the days Nearly every day
Trouble relaxing
-- select -- Not at all Several Days More than half of the days Nearly every day
Being so restless its hard to sit still
-- select -- Not at all Several Days More than half of the days Nearly every day
Becoming easily annoyed or irritated
-- select -- Not at all Several Days More than half of the days Nearly every day
Feeling afraid as if something awful may happen
-- select -- Not at all Several Days More than half of the days Nearly every day
Problems around food?
-- select -- Yes No Don't know
Problems with drugs &/or alcohol?
-- select -- Yes No Don't know
Physically hurt or forced to have unwanted sexual contact?
-- select -- Yes No Don't know
Self harm?
-- select -- Yes No Don't know
Young people (11-18 years only) - We will offer all young people 6 sessions of counselling which will be reviewed with your counsellor.
Adults 18+ - We will offer adults up to nine sessions of counselling which will be reviewed with your counsellor