Client Self‑Referral Form

Please complete and submit this confidential registration form. You may also email this directly to contact@ontimetherapy.com. I aim to contact you within 48 hours of receipt.

Strict Confidentiality & GDPR

All information submitted is protected under UK/Jersey data laws, stored on encrypted drives, and handled in accordance with the ACCPH & NMC ethical standards.

Crisis Support Notice

Outpatient counselling is not for acute crisis. In an emergency, dial 999 or phone the Samaritans at 116 123.

1. Personal Details

Your Full Name *

Date of Birth (DOB) *

Full Residential Address *

2. Contact Details & Communication Preferences

Phone Number *

Emergency Contact Number *

Email Address *

Best Time to Contact You

Preferred Communication Method *

3. Therapeutic Focus & History

What would you like to address in counselling? *

Previous Counselling Experience

4. Medical, Psychiatric & Safety Indicators

Medical or Psychiatric History

Upcoming Medical or Psychiatric Appointments

History of Self‑Harm, Overdose, or Violence

5. General Practitioner (GP) Details & Consent

GP Details (Doctor's Name, Surgery Name, Practice Address, Phone) *

Consent to contact GP: *

Your GP will only be contacted for care coordination or if significant safety/safeguarding risks arise.

YESNO

6. Declaration & Electronic Signature

I confirm that the information provided on this form is correct and I have reviewed the Online Counselling Agreement. I understand the confidentiality terms, session conditions, and cancellation policies of Ontime Therapy Services.

Electronic Signature (type your full name) *

Date *