Registration Form

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. 


Please tick one option
Please indicate:
Date of first Confirmed Appointment
Date of first Confirmed Appointment
Name *
Name
Address (Home) *
Address (Home)
Date of Birth *
Date of Birth
Relationship Status (Optional)
Please tick all that apply
e.g. 5 years together / broke up 3 months ago / partner has 3 children from previous relationship.
Please indicate the details of your Family of Origin e.g. Mother & Father (Separated in 1967 - I was 5yrs old) e.g. Siblings: Sean 34 (oldest), Mary 23, Me 20, Joan 17 e.g. Mum (R.I.P. 2010), Dad, Jean (Stepmum)
Please list Name & Age of your children and any significant information (i.e. Paul 3yrs oldest, Mary 3mths / Denis 22, diagnosed with M.S. in 2014)
Please provide the name, address and telephone contact of your current Medical Practitioner (your GP/Clinic +/ Psychiatrist)
Please indicate if you have a medical condition that is important for our practitioners to know in case of an event. Example: epilepsy, pregnancy related conditions, narcolepsy. Or NA for not applicable.
Please provide: 1. Name / Age / Sex of Adolescent. 2. Your relationship to this adolescent. 3. Please indicate any involvement from other parties (GP / Police / Youth Worker) and their details. 4. Please briefly describe what is happening for this young person. Is this young person willing to attend counselling? 5. Please indicate who will accompany the adolescent for counselling.
How did you hear about Erich Keller Counselling?
Please tick all that apply.
Survey (Optional)
Survey (Optional)
I am happy to fill out this form at home before my first session
I am happy to fill out this form during my first session with my therapist
Declaration in place of electronic signature *
Declaration for Legal Guardian of Adolescent &/or Third Party (if applicable)
Applicable for Legal Guardian of Adolescent and for those who are filling out this form on behalf of another adult.