Counselling Self-referral Form

General Information

This application form should be used to apply for counselling at Projekt 42.

In accordance with the Data Protection Act 2018, your permission is needed for us to collectand keep any personal data whether by manual or electronic means. So that your counselling or therapy runs smoothly and you can be contacted if necessary, the service needs to collect and process personal data. Some of the information we may collect is classified as sensitive personal data and we can only use such data where we have your explicit consent. Your personal and sensitive personal data will only be used in order to provide the service to you and for managing and quality assuring the service. We, therefore, request that you sign below giving us the necessary permission to keep such data as you are willing to disclose and for confidential records to be kept about your attendance and counselling. This in no way affects the confidentiality of your counselling. The only time this would be compromised is when the safety of you or someone else has been identified as a concern.

Counsellors keep notes to ensure continuity in the counselling process, but these are confidential to each individual counsellor, and are securely stored and will be kept for seven years and then destroyed.

Projekt 42 collates statistical information about its work and its clients. This is used for policymaking, statistical and promotional purposes. In all cases, this does not identify individual clients.

Information about the service published in the annual report is of a statistical nature and is anonymous, as is any feedback is given to employers if you attend through an employee assistance scheme.

Projekt 42 recognises that on rare occasions you may wish to exercise your rights under the General Data Protection Regulation May 2018 and make a subject access request in respect of your personal information held by Projekt 42 or Counsellors. If at any time you wish to exercise your right under the Act, please contact the Administrator in the first instance and you where possible we will supply these to you free of charge within a month. Please see our Client Information - Procedure for Subject Access Requests.

About You

In order to help you access counselling, we need to know a little information about you.

Contact in case of Emergency

Sometimes, with your permission, we will contact someone who cares about you. Who would you like this to be? We won't ever contact this person without your permission.

Your Therapy & Preferences

Each counsellor is trained in a range of counselling, life coaching and psychotherapy approaches. This enables us to tailor our approach to suit your learning style, giving you the best opportunity for positive results.

The range of therapies we provide includes counselling, psychotherapy, cognitive behavioural therapy (CBT), psychodynamic.

At the time of meeting a member of our counselling team, we will discuss the options available to you, from long-term therapy to short-term counselling.

Please tick the issue(s) that you feel apply to you. Areas that you highlight below can be talked through with your counsellor. The issues below do not need to be diagnosed conditions but relate more to how you feel and what you feel is effected your mood. Feel free to also explain what difficulties you are currently experiencing in the next question below.

GP Consent

There may be occasions where, with your permission, we can contact your GP to let them know that you are working with our counselling team.

Costs, Payment & Cancellation Terms

Although we are a charity, our activities are not government funded. The service is subsidised by the sale of our fitness and yoga classes.


The cost of a counselling session is based on a sliding scale from £25.00 to £55.00 per session depending on your annual gross income:

Under £20,000   -            £25.00 per session          £20,000 - £24,999  -        £35.00 per session          £25,000 - £29,999  -        £45.00 per session     £30,000 - £34,999  -        £50.00 per session         Over £35,000  -                £55.00 per session

Should you receive a funded or part-funded counselling appointment the mental health team may require supporting evidence.

Payment & Cancellation Terms

Sessions must be paid for in advance of your appointment and any appointment cancellations must be made at least 48 hours before your appointment. Missed sessions must be paid for. This is to ensure that the charity's costs are covered.

What happens next

When you submit the self-referral form, you will receive an email to confirm that we have received your form.

Your referral will then be checked by management and if any further information is required we will contact you to discuss your referral. Usually, we will email you. In the past some of our emails have been sent to the junk folder so please check your inbox and junk folder.

We will contact you on a regular basis to advise that you are still on our waiting list. We aim where possible to work with clients within 10 weeks of the self referral having been completed.

At the time of an appointment being issued, we will provide you will a brief overview of what you can expect from the counselling services at Projekt 42.

We hope that we will be able to match you with a counsellor soon.