Enquiry Form

Your Full Name*

Full Home Address*

Telephone*

Email*

If you are a parent referring a child, please complete child's name and date of birth below.

Name of Child

Child's Date of Birth

Main Issues (select all that apply)*

Anxious/ excessive worrying

Appetite changes/eating disorder

Defiant

Depression/ low mood

Excessive changes in energy

Hyperactive

Impulsivity

Inattentiveness

Increased agitation

Math difficulties

Overall poor educational progress

Physical aggression

Poor assessment of risk behaviour

Poor problem solving

Poor social skills

Property damage

Quick emotional fluctuations

Reading comprehension difficulties

Reading difficulties

Sexual aggression

Sleep changes

Speech difficulties

Spelling difficulties

Suicidal thoughts

Suspension/expulsion

Verbal aggression

Victim of abuse

Writing difficulties

Other

Please answer these questions as best you can, in the box below. What have you/your child been experiencing? How does this effect day to day life? What do you/your child want to change? What do you/your child hope to get from counselling sessions?*

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Email: letstalk@littlelighthousecounselling.co.uk

Tel: 01922 663644

West Midlands House
Gipsy Lane
Willenhall
West Midlands
WV13 2HA

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