Initial Assessment Form for Counselling                        

This is the initial assessment application form if you would like to apply for counselling or play therapy for yourself or a child. The information you supply will be kept in the strictest confidentiality in line with BACP guidelines. Please complete the form in full.

If the application is for a child, the parent will need to give parental consent for us to provide counselling or play therapy. Information divulged by the child would not normally be shared with the parent or guardian.
The initial assessment will be over the telephone and will be free of charge.

Applicant Details


About The Child

If the counselling is for a child, please complete this section of the form. We would normally provide child counselling within school or at our counselling room at our offices in Halifax.

Do you authorise YCT to provide counselling/play therapy services to my child?

Payment Details

Background Information

Please provide any background to why you are signing up for counselling, if you prefer to discuss this on the telephone, please just enter "To be discussed on the telephone" in the information box below.

Acceptance Declaration

This is my application for an initial assessment with a trained counsellor with Yorkshire Children's Trust. If I provide details of a child, I agree to the services being provided and understand the counsellor will not divulge any information shared by the child. I understand the initial assessment is provided free of charge, but future sessions, however provided will be at the costs discussed with me during my initial assessment. 

I agree to Yorkshire Children's Trust, its agents and staff to use my information to provide me with the services of the charity and that I may be contacted by telephone, text message, traditional post or email unless I notify the charity otherwise in line with the Charity GDPR & Privacy Policy.

I understand that any information divulged to the charity during my initial assessment and future sessions will remain confidential and will not be shared with any outside agency unless there is a risk to life to you or another person, it pertains to a criminal activity or an act of terrorism. 
The full terms and conditions of the Counselling Service provided by Yorkshire Children's Trust are available on request.

Yorkshire Children's Trust

Registered Charity Number 1146884



Telephone 01422 72 80 80

YCT House  70 Commercial Street  Halifax • HX1 2JE

© 2011-2020 A registered charity limited by guarantee, number 10650385