Charlies-Angel-Centre Foundation Bereavement Counselling Assessment Form

Charlies-Angel-Centre Foundation Bereavement Counselling Assessment Form
When submitting a form for bereavement counselling, please consider the commitment this takes and if you are ready for counselling, if you are not sure, you can discuss this with us, we are here to help
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
Date Of Birth
Male or female
Would you like to be contacted by Email or Telephone?
Gp Details
Who can we contact in case of an emergency? Family, friend,please include a telephone number
Note, We will not normally contact this individual and will only do so if we asses you as being at serious risk, In the unlikely event that we need to contact him/her, we will only do so on a;need to know basis& and wherever possible , in consultation with you.
Please give details of why you wish to access this service
Would you prefer face-face, zoom or telephone counselling
Your availability
Where did you hear about our service?
Pre-assessment The aim of this form is to help the counsellor who you will be assigned to understand whether you have any previous mental-health history and whether any health considerations need to be in place during your sessions.
Signature
Date
Charlie’s Angel Centre Foundation Bereavement Counselling Equal

Opportunities Monitoring Form

Charlie’s Angel Centre Foundation is committed to ensuring that all service users are treated equally, without discrimination on the grounds of gender, sexual orientation, marital or civil partner status, gender reassignment, race, colour, nationality, ethnic or national origin, religion or belief, disability or age. This form is intended to help us maintain equal opportunities best practice and identify barriers to equality and diversity.

The information on this form will be used for monitoring purposes only and will play no part in the counselling assessment process. All questions are optional. You are not obliged to answer any of these questions but the more information you supply, the more effective our monitoring will be. All information supplied will be treated in the strictest confidence.
Gender
Age Group:
Do you live and work in a gender other than assigned at birth?
Please select the option which best describes your sexuality
The Equality Act 2010 protects disabled people.Do you consider yourself to have a disability?
If you ticked yes, please state the impairment(s) which apply to you
How would you describe your religion or belief:
I would describe my ethnic origin as:
Black
white
mixed
Other Ethnic Group
Undisclosed
Thank you for taking the time to complete this form
Should be Empty:

Charlies-Angel-Centre Foundation Bereavement Counselling Assessment Form

When submitting a form for bereavement counselling, please consider the commitment this takes and if you are ready for counselling, if you are not sure, you can discuss this with us, we are here to help

Thank you for taking the time to complete this form