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New Client Form

Thank you for your interest in my counselling and psychotherapy services. To book in an appointment, I will need to collect a few details from you.


Please fill out the form below or if you would prefer, we can arrange to do this by phone. This will cut down the amount of admin to be done in our first session so we can spend more time talking.


Only items marked with an asterisk (*) are required but please complete as much of the form as you can. Once I receive your form, I'll be in touch by phone or email.


More information about how I collect, store and process your details can be found in my privacy policy which can be viewed online by clicking here

How can I get in touch with you? Please select all that apply.
Date of Birth
Day
Month
Year

Note: I can only offer my services to people aged 18+

Note: I can only offer my services to people based in the United Kingdom

Pronouns
How would you like to access therapy?

Note: my practice is currently open between 9am and 6pm on weekdays

Document with Pen

Contact Me

Counselling room with phone and laptop and laptop

You can contact me by phone, email or if you'd prefer, use the form below to send me a message.

I look forward to hearing from you.

Phone: 07454 229155

Email:  domjamescounselling@gmail.com

Thanks for your message. I'll aim to get back to you as soon as I can.

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