This form can be competed online and send to Philippi or you can and send the completed form by post to the address below.

233 Kings Road, Reading, Berkshire RG1 4LS Tel: 0118 966 7422 Email: reading@philippitrust.freeserve.co.uk Registered Charity Number 1016105

Application for Counselling - CONFIDENTIAL

Title:		Full Name:
Address:
Post Code:
Tel No:			Mobile:
Email:
Occupation:			Date of Birth:
Family Details:
Doctor:
Have you ever suffered any serious medical problems?			Yes	No
details:
Have you ever suffered from any form of psychiatric illness?			Yes	No
details:
Prescribed drugs
Other information you think we ought to be made aware of:
Previous Counselling:
How would you define your problem?
How do you see us being able to help?
How were you made aware of Philippi?
Do you have any special requirements?
If you have a strong preference for either a male or a female counsellor, please state your preference here (Please be aware this may affect the waiting time)
Please indicate days, times and telephone numbers where we can contact you:
Are you happy for us to leave messages on your answer phone?			Yes	No

When would be the most suitable times for counselling? Please give as many choices as possible:-
Tuesday	Morning		Afternoon		Evening
Wednesday			Afternoon
Thursday	Morning		Afternoon		Evening
If you have any difficulties at all in completing this form, please telephone the office and we will offer you all the help we can