John Turton - The Counsellor Enquiry Form

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The Counsellor Enquiry Form

Please use this form for genuine enquiries for help or to make contact with the Counsellor.

IF you are in an EMERGENCY situation such as suicidal tendencies or medical situations please use the LOCAL emergency number in your own national/regional location as this service is NOT an emergency service.

Counsellor Enquiry Form

Your Present first and last names:

Email:
Gender (please click which is true of you) : Male Female

Birthdate:
DAY MONTH: YEAR:

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Do you have any particular questions you'd like to ask?

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If you'd like to give a brief description of what's happening, describe any recent changes or long-term problems you have experienced in each of the five areas.

HINTS

Environmental changes/Life Situations
Have I experienced any recent changes? What have been the most stressful events for me in the past year? 3 years? 5 years? In childhood? Do I experience any long-term or ongoing difficulties (including discrimination or harassment by others?

Physical Reactions
Do I experience any physical symptoms that trouble me, such as changes in energy level, appetite, and sleep, as well as specific symptoms, such as heart rate fluctuations, stomach aches, sweating, dizziness, breathing difficulties, or pain?

Moods
What single words describe my moods (angry, depressed, anxious, hurt, jealous, envious, shameful...)?

Behaviours
What things do I do that I would like to change or improve? At work? At Home? with friends? By myself? Do I avoid situations or people when it might be to my advantage to be involved?

Thoughts - Images - Memories
When I have strong moods, what thoughts do I have about myself? Other people? My future? what thoughts interfere with doing the things I would like to do or think I should do? What images or memories come into my mind?

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Send me of the information I have shared please (requires correct email address at the top)

Please share any additional information you think might be helpful....

ALL ENQUIRIES ARE PRE-SCANNED FOR SPAM OR PHISHING DEVICES

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John Turton - Online Counsellor (NZ)

The Counsellor Enquiry Form