Self Assessment Form for Cognitive Behavioural Therapy (CBT) & Counselling

Self Assessment Form

If you are unsure whether Clear Therapies can help, fill in the form below summarising your issue in no more than 1000 words (2 pages) and we will get back to you

* Indicates required field

Name *

First

Last

Email *

Primary issue *

Secondary issue *

Presenting Issues *

I agree to receiving marketing and promotional materials *

Submit

Please note although we endeavour to get back to you as soon as possible Clear Therapies is not a Crisis Service, if you need immediate support please contact your GP, NHS Direct, Crisis Team or Emergency Services if it urgent.

All information is held confidentially, your details are only passed onto other services (e.g. NHS Crisis Team or Police) if there is a potential risk to yourself or someone else or if there is a legal requirement to pass on the information. All client details are deleted if they are not accepted for treatment and after discharge from treatment.

Site Map

Top: Therapy Options: Am I Suitable? Treatment Options Fees

Homepage What is CBT? Self Assessment Form Face to Face Sessions Testimonials

What is Counselling? Telephone Sessions FAQs

Therapy Team HD Internet Video Conferencing Sessions Contact Us

Email Sessions