HERE 4 YOU | Tyrese Caesar

YOU DON'T HAVE TO FACE IT ALONE

GROUP COUNSELLING REGISTRATION FORM

All information is strictly CONFIDENTIAL

Please complete all sections clearly. You may omit any question that does not apply to you.

Fields marked with * are required.

SECTION 1 — PERSONAL BACKGROUND

First name

Last name

Date of Birth

Age

Gender

Address

Primary Phone

Secondary Phone

Where Is It Okay To Leave A Message?

Employer / School / Organisation

SECTION 2 — COUNSELLING & MEDICAL BACKGROUND

Did You Have Any Previous Counselling?

When?

Where?

Rate Your Current Physical Health:

Do You Currently Have A Physician / Doctor?

Who?

Where?

Please List Any Medications You Are Currently Taking (including contraceptive pills). Write 'None' if not applicable:

SECTION 3 — GOALS, INTENTIONS & EXPECTATIONS

Please Summarise Your Specific Goals And Expectations For This Group * (use additional page if needed):

Is There Anything Specific You Would Like The Counsellor To Know Before Your First Session?

SECTION 4 — CONSENT & DECLARATION

CONFIDENTIALITY: All information provided in this form will remain strictly confidential and will be used solely to provide you with appropriate counselling support through the Here 4 You programme. Your details will not be shared with any third party without your explicit consent, except where required by law or where there is a serious risk to safety.

GROUP PARTICIPATION: Group counselling sessions involve sharing in a safe, facilitated environment. All participants agree to maintain the confidentiality of other group members. Our counsellors are trained professionals committed to creating a respectful and supportive space for everyone.

DATA & RECORDS: By submitting this form, you consent to Here 4 You / The Tyrese Caesar Foundation storing your information securely for the purposes of providing support services. You may request access to or deletion of your records at any time by contacting us.

Please Tick All That Apply:

I understand and agree to the confidentiality policy outlined above.

I confirm that the information I have provided is accurate and complete to the best of my knowledge.

I understand what group counselling involves and I agree to participate respectfully and openly.

Signature

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Date

YOU DON'T HAVE TO FACE IT ALONE

GROUP COUNSELLING REGISTRATION FORM

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