Either complete and send as email attachment, if not on a public computer; or print and post
in envelope marked “confidential” (or deliver by hand) to:
The Counselling Service, King's College London, Strand, London WC2R 2LS.
You will be contacted with an appointment as soon as possible.

Today’s                                          Date of
Date:                                            Birth:

First Name:                                     Surname:

Subject or                                                            Year of
Department:                                                           study:

Male                 Undergraduate                Full-time              Staff

Female                  Graduate                  Part-time

                                                   If UK,
                                                Ethnic Origin:

Term time Address:                             Home Address:

Telephone:                                    Mobile:


Name, Address & Phone Number of your G.P.

How did you hear of the Service?
Can you attend:     Strand           Waterloo                Guy’s             Denmark Hill

Please tick when you ARE available to attend - the better your availability, the sooner
the appointment:

                  Monday          Tuesday        Wednesday            Thursday         Friday

Whilst we make every effort to see students on the site and at a time requested,
this is NOT always possible. Students who wish to be seen may be asked to
attend at a different time or site.

Have you seen a counsellor HERE before?                      yes                           no

If yes, who did you see and when?

Please put a tick in the appropriate column:                        Not                         Most of
                                                                   at all                       the time
1. I have felt very alone and isolated
2. I have thought of hurting myself
3. I feel I have someone to turn for support when needed
4. I have had thoughts of not wanting to go on living
5. I have been disturbed by unwanted thoughts and feelings
6. I have felt hopeless
7. I have been able to do most things I needed to

It would be helpful if you could briefly explain why you wish to see a counsellor:

Please confirm you have read the attached “Code of Practice on Confidentiality &
Data Protection”:

Tick here, if sending the completed form as an email attachment

Or sign here, if sending it by post or delivering by hand:

Signed …………………………………………………………………………..


Student Counselling and Welfare Services

Code of Practice on Confidentiality and Data Protection
This leaflet outlines our responsibility and practices in respect of information on
clients and explains our policies on confidentiality and data protection


Staff of the Counselling Service will not pass on personal information about a client
(including information on attendance) to anyone outside the Service subject to the
following exceptions:

   Where a member of the Counselling staff has the permission of the client to
    disclose the information or data

   Where a member of the Counselling staff would be liable to civil or criminal court
    procedure if the information was not disclosed

   Where a member of the Counselling staff believes the client is in serious danger to
    self and others.

In any of these circumstances, the counsellor will normally encourage the client
him/herself to pass on information to the relevant person/agency. If there is no
indication that this has happened, and if the crisis or danger is sufficiently acute, the
counsellor may pass on the information directly.

Consent to disclose information will be sought from the client, if at all possible.


In line with their professional requirement counsellors may discuss their work with a
consultant external to the Service. In this process, the identity of the client is not
revealed. The purpose of consultation is to help the counsellor or adviser reflect on
their work.

Liaison and correspondence

With the permission of the client it may be appropriate for the counsellor to liaise
with or write to a third party, for example, a member of university administration,
personal tutor, or General Practitioner or Psychiatrist. In the case of telephone calls,
the purpose of the call will be discussed with the client prior to the call.
Record Keeping and Data Protection

It is usual practice for counsellors to keep records on clients and their sessions.
Counselling notes record background information and the issues raised and worked on
in the sessions. These will vary in length and detail. Points of concern are also noted.
All notes are kept safely under lock and key.

Access to notes

Under the Data Protection Act, clients have a right of access to all notes kept on them.
If those notes contain references to other individuals, these may only be made
available to the client if a third party’s anonymity is protected. It will be important
not just to show the notes to the client, but for the adviser or counsellor to talk to them
about what their file contains and why. Some notes are in shorthand and may need

If a client’s file includes a letter or additional information from the person responsible
for their clinical care, usually their GP or psychiatrist, consent from the relevant
practitioner must be obtained before the correspondence is disclosed.

If a client wishes to see their file, they should ask their adviser or counsellor giving at
least two weeks’ notice.


All notes and records are kept securely locked within the Service.

In line with legal requirements, an adviser’s notes are kept for a period of 7 years and
counselling notes are kept for 5 years. After this time they are destroyed by

Codes of ethics

The staff in the Counselling Service adhere to British Association for Counselling and
Psychotherapy Code of Ethics and Practice and The British Psychological Society and
the GMC.

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