Therapy consent | Beyond Reflections

Therapy consent to share

Are you still interested in Beyond Reflections counselling/therapy support?

Yes

Date

Type of therapist wanted

I would prefer:

Online

In person (southampton)

In person (other areas) (if selecting this option please also select a second choice)

Declarations

I agree that I will pay the extra monthly charge of £15 per month on top of my current membership cost if I request a qualified therapist and turn down support from a placement student

I give Beyond Reflections permission to share details about me with a volunteer counsellor for the purpose of allocating me support, including, if applicable, a volunteer working in private practice

I have read and accept the counselling agreement

Counselling agreement

I understand that this will be considered my digital signature for the purposes of this form

If you are a human, ignore this field