Couples Counselling Enquiry

Thank you for your interest in couples counselling.
Please complete this short form, and I’ll be in touch to arrange a complimentary 15-minute discovery call to see if we’re a good fit to work together.

All information shared is held in confidence.

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Name (Partner 1) *

First

Last

Name (Partner 2) *

First

Last

Email *

Email

Confirm Email

Phone *

What brings you to couples counselling at this time? *

Please share briefly what’s been happening and what you hope might change through therapy.

How long have you been together? *

Are you currently living together *

• Yes
• No

Have either of you attended counselling before? *

• Yes
• No

If yes, please give a short description:

Preferred Session Format *

• Online
• In-person
• Hybrid

you currently How

GDPR Agreement *

• By submitting this form, you consent to Christina Richards Counselling securely storing and processing the personal information you provide. Your details will be used only for the purpose of responding to your enquiry and arranging counselling sessions if appropriate.

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