Counselling Form – Heart Work

Contact information, Identity, Occupation.

First Name *

Last Name

Preferred Name *

Email *

Phone *

Address

Preferred Pronouns *Her/SheHe/HimThey/ThemChoose your own

Choose your own pronoun

Date of Birth

Age *

Preferred method of communication *Text/Mobile PhoneEmail

Are you in a relationship? If so, for how long? *

How would you describe your cultural identity, ethnicity, and/or heritage? *

Do you currently have a job e.g., paid, unpaid, volunteer, student, carer, parent? *YesNoOther Roles

Emergency contact Details

Emergency contact *

Relationship *

Phone No *

Health Matters

Do you have any disabilities? *YesNo

Please list further details about your disability and/or potential support needs below *

Do you identify as neurodivergent? *Yes, I am a person with autismYes, I am person with allistic (non-autistic) neurodivergencyYes, I have lived experience with dyslexia, dyspraxia and/or dyscalculiaYes, I have lived experience with tourettes and or ticsYes, I have a combination of neurodivergent lived experiences that apply to meYes, I have cognitive needs that affect my executive functionNo, I am a neuro stereotypical person (often called neurotypical)Not sure or unfamiliar with the concept neurodivergencePrefer not to say

Are there any other needs you might have? *Kinship and CulturalPrevious work related traumaMental health concernsCareer responsibilitiesNone/do not wish to discloseOther (please provide details):