The registration form below is required for administration purposes. It also gives our therapists helpful information about you. Some of the fields are mandatory and some are optional. Mandatory fields are indicated with an asterix *
Please write 'Rather not say' or 'Not applicable' to questions you do not wish to answer. You can discuss this further with your therapist. We understand that some of this information may be private and sensitive.
There is no obligation on your part to complete this form before your first appointment. Your therapist will be happy to assist you when you meet.
Please note however that the mandatory fields indicate the minimum information needed to begin counselling.
You will also have the opportunity to discuss all aspects of this form and the information you have provided within the first and subsequent sessions with your therapist.
The information given by you will be held under the Irish Data Protection Acts 1988 & 2003 and will not be shared with any third party without your consent. Please click here for more information on Data Protection.
Please contact us at erich@erichkellercounselling.com or call 086 - 120 6151 if you have any questions about this form.
Thank you for taking the time to complete this online Registration Form.
