Student Counselling Service
- Room 12 Crosby Hall. Disted College
Counselling Intake Form (Online Version) - PART A
in this form is requested for record-keeping and statistical purposes;
it will not be used outside the Service in any way that identifies
individuals. You can complete the form digitally. DO NOT FORGET TO
CLICK ON THE SUBMIT BUTTON AT THE BOTTOM OF THE PAGE WHEN YOU HAVE
COMPLETED THE FORM.
Who suggested that you came to see a counsellor? (Please tick)
Please fill in the
boxes below to show your availability: ‘Y’= available; ‘?’= may be
available; ‘N’ = not available. We will try and offer times when you are
available but may offer non-preferred times to reduce the waiting period.
Very restricted availability is likely to delay counselling.
Please sign to
indicate that you have read the ‘Information for anyone thinking about
counselling' (available at:
continue to Part B
To be filled in
by the CCAT Student Counselling Service @ Disted
you provide here will help us to understand your needs and arrange for you
to see an appropriate counsellor, so it is useful to have some information
about the problem, even if brief. This information will be treated
1. Your reasons
for approaching the Counselling Service
what has led you to your seek counselling now. How long has this been a
problem for you — and what other help have you had with it? How do your
current difficulties affect you?
2. What are you
hoping for from counselling?
What would you like
to gain from counselling now? How would things be different if the
difficulties were resolved?
3. Much of our
work involves workshops and groups of various kinds.
whether these might interest you?
Structured groups with a focus on practical strategies:
4. Is there
anything else that you think is important which we should know?