0116 254 4341
For when a child dies or is bereaved
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Counseling Contract and Consent – please read carefully confirming each section
Counseling details
Informing your GP(s)
Adult(s) Detail
Child(ren) Details
Consent
Code of Ethics - All counsellors have completed or are working towards completion of relevant professional training as well as specialised training in bereavement. They are either registered or working towards registration with a professional body (BACP or UKCP). All counsellors work to the British Association of Counselling and Psychotherapy (BACP) code of ethics, which can be found at www.bacp.co.uk
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I have read the statement above
Confidentiality and exceptions - Respecting your confidentiality is of the utmost importance to us, wherever possible we keep your information confidential within The Laura Centre. All counsellors discuss aspects of their client work with their clinical supervisor; this is a confidential professional relationship. Unless you have given us permission or asked us to share information, we will aim to keep confidentiality (as above). However, if it is assessed that there is a serious risk of harm to yourself or others, it may be necessary to alert other people, such as your GP of our concerns. Careful consideration should be given before disclosing anything of a previously unreported criminal nature because The Laura Centre needs to comply with the law and may find it necessary to notify other agencies, particularly when the protection of children and vulnerable adults is a concern. Depending on the particular circumstances, we would aim to discuss disclosure to others with you beforehand wherever possible.
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I have read the statement above
Records - The Laura Centre meets and upholds the principles of General Data Protection Regulation (GDPR). Standard professional procedure requires that summary notes be made by your counsellor. These notes are usually very brief and are stored on a secure database at The Laura Centre. Your name and address will not appear on the notes. We produce summary statistics of users of the Centre and these are publicly available e.g. according to ethnicity, age, the general cause of death. (Please ask if you want full details of our data protection policy).
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I have read the statement above
Fees - The service is free at the point of need. However, any donation would be appreciated. You might like to consider making a regular donation when you attend sessions.
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I have read the statement above
Complaints - If you are unhappy with the support you receive from your counsellor, we encourage you whenever possible, to talk through your concerns with them. If this is not possible or they are unresolved, please raise your concerns with the Director of Therapeutic Services or Chief Executive of The Laura Centre. A copy of our complaint procedure is available in the waiting room or from reception.
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I have read the statement below
Cancellation/DNA Policy - If you are unable to keep a planned appointment we would appreciate as much notice as possible (preferably more than 2 working days), please telephone 0116 254 4341. If the office is closed you can leave a message on our answer machine. Appointments which are cancelled on the day, will be classed as a ‘did not attend’ appointment. If you do not attend or give us notice about cancelling for two appointments in a row, we will not contact you and your case will be closed. If you have any further appointments booked, these will be cancelled. If you contact us later you may need to wait before being offered an appointment.
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I have read the statement above
Agreement with your counsellor - This is a working agreement aimed at providing you and your counsellor with boundaries and a structure within which to work. It is also possible to renegotiate this agreement or add other agreements in the course of the counselling contact. Indeed, during the first session of counselling your counsellor will: • explain more about the process of counselling, including their specific way of working • confirm our agreement about confidentiality and discuss boundaries, for instance agree a response to a chance meeting elsewhere • discuss timings of sessions and the importance of punctuality • come to an initial agreement on the number of sessions and how counselling will be reviewed • highlight the procedure for cancelling an appointment – either by you or the counsellor • agree the procedure for resuming counselling after an unplanned interruption, for example, through illness.
I have read the statement above
GP Contact
As part of the partnership of health and community services we sometimes share information with GP's. Please indicate (by ticking the box/es) that you consent to this information being shared.
GP contact (Health) - I understand that my GP may be contacted if someone’s health or wellbeing might be at risk
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I agree with the statement above
GP Contact (Initial) - I am happy for my GP to be informed that I/my child/ren have attended an initial meeting at The Laura Centre (optional)
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I agree with the statement above
I do not agree with the statement above
First Name
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Last Name
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Email
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Email
Confirm Email
Disability
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Disabled
Not Disabled
Prefer not to say
Please indicate level or type of disability (optional)
Ethnicity
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White - English/Scottish/Welsh/Northern Irish/UK
White - Irish
White - Gypsy or Irish Traveler
Mixed Ethnic - Mixed Ethnic Background
Asian / Asian UK - Indian
Asian / Asian UK - Pakistani
Asian / Asian UK - Bangladeshi
Asian / Asian UK - Chinese
Other Asian Background
Black / Black UK - African
Black / Black UK - Caribbean
Black / Black UK - Other Black Background
Other Ethnic Group - Arab
Other Ethnic Group - Other
Other Ethnic Group - Prefer not to say
Sexual Orientation
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Heterosexual
Lesbian/Gay/Bisexual/Transgender/Asexual
Prefer not to say
Religion
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No Religion
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Prefer not to say
Do you need to add details of a second adult
Yes
No
First Name - second adult
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Disability - second adult
*
Disabled
Not Disabled
Prefer not to say
Last Name - second adult
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Please indicate level or type of disability adult 2 (optional)
Ethnicity - second adult
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White - English/Scottish/Welsh/Northern Irish/UK
White - Irish
White - Gypsy or Irish Traveler
Mixed Ethnic - Mixed Ethnic Background
Asian / Asian UK - Indian
Asian / Asian UK - Pakistani
Asian / Asian UK - Bangladeshi
Asian / Asian UK - Chinese
Other Asian Background
Black / Black UK - African
Black / Black UK - Caribbean
Black / Black UK - Other Black Background
Other Ethnic Group - Arab
Other Ethnic Group - Other
Other Ethnic Group - Prefer not to say
Sexual Orientation - second adult
*
Heterosexual
Lesbian/Gay/Bisexual/Transgender/Asexual
Prefer not to say
Religion - second adult
*
No Religion
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Prefer not to say
Child(ren) details - yes or no. If no please click 'Next'
No, I do not need to any details of children
Yes, I need to add details of children
First Name - child
*
Ethnicity - Child
*
White - English/Scottish/Welsh/Northern Irish/UK
White - Irish
White - Gypsy or Irish Traveler
Mixed Ethnic Background
Asian / Asian UK - Indian
Asian / Asian UK - Pakistani
Asian / Asian UK - Bangladeshi
Asian / Asian UK - Chinese
Other Asian background
Black / Black UK - African
Black / Black UK - Caribbean
Black / Black UK - Other Black background
Other Ethnic Group - Arab
Other Ethnic Group - Other
Prefer not to say
I need to add details for a second child
Yes
Last Name - child
*
Religion - Child
*
No Religion
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Other
Prefer not to say
Disability - Child
*
Disabled
Not Disabled
Prefer not to say
Please indicate level of disability (optional) child
First Name - child 2
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Ethnicity - Child 2
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White - English/Scottish/Welsh/Northern Irish/UK
White - Irish
White - Gypsy or Irish Traveler
Mixed Ethnic Background
Asian / Asian UK - Indian
Asian / Asian UK - Pakistani
Asian / Asian UK - Bangladeshi
Asian / Asian UK - Chinese
Other Asian background
Black / Black UK - African
Black / Black UK - Caribbean
Black / Black UK - Other Black background
Other Ethnic Group - Arab
Other Ethnic Group - Other
Prefer not to say
I need to add details for a third child
Yes
Last Name - child 2
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Religion - Child 2
*
No Religion
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Other
Prefer not to say
Disability - Child 2
*
Disabled
Not Disabled
Prefer not to say
Please indicate level of disability (optional) child 2
First Name - child 3
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Ethnicity - Child 3
*
White - English/Scottish/Welsh/Northern Irish/UK
White - Irish
White - Gypsy or Irish Traveler
Mixed Ethnic Background
Asian / Asian UK - Indian
Asian / Asian UK - Pakistani
Asian / Asian UK - Bangladeshi
Asian / Asian UK - Chinese
Other Asian background
Black / Black UK - African
Black / Black UK - Caribbean
Black / Black UK - Other Black background
Other Ethnic Group - Arab
Other Ethnic Group - Other
Prefer not to say
I need to add details for a fourth child
Yes
Last Name - child 3
*
Religion - Child 3
*
No Religion
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Other
Prefer not to say
Disability - Child 3
*
Disabled
Not Disabled
Prefer not to say
Please indicate level of disability (optional) child 3
First Name - child 4
*
Ethnicity - Child 4
*
White - English/Scottish/Welsh/Northern Irish/UK
White - Irish
White - Gypsy or Irish Traveler
Mixed Ethnic Background
Asian / Asian UK - Indian
Asian / Asian UK - Pakistani
Asian / Asian UK - Bangladeshi
Asian / Asian UK - Chinese
Other Asian background
Black / Black UK - African
Black / Black UK - Caribbean
Black / Black UK - Other Black background
Other Ethnic Group - Arab
Other Ethnic Group - Other
Prefer not to say
I need to add details for a fifth child
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Yes
Last Name - child 4
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Religion - Child 4
*
No Religion
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Other
Prefer not to say
Disability - Child 4
*
Disabled
Not Disabled
Prefer not to say
Please indicate level of disability (optional) child 4
First Name - child 5
*
Ethnicity - Child 5
*
White - English/Scottish/Welsh/Northern Irish/UK
White - Irish
White - Gypsy or Irish Traveler
Mixed Ethnic Background
Asian / Asian UK - Indian
Asian / Asian UK - Pakistani
Asian / Asian UK - Bangladeshi
Asian / Asian UK - Chinese
Other Asian background
Black / Black UK - African
Black / Black UK - Caribbean
Black / Black UK - Other Black background
Other Ethnic Group - Arab
Other Ethnic Group - Other
Prefer not to say
Last Name - child 5
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Religion - Child 5
*
No Religion
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Other
Prefer not to say
Disability - Child 5
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Disabled
Not Disabled
Prefer not to say
Please indicate level of disability (optional) child 5
I/we understand the type of support offered by The Laura Centre. I understand that the Centre works within BACP ethical framework and abides by policies on confidentiality, record keeping and data protection. I have been given information about these policies. I consent for my GP to be contacted as indicated in this document. I/we wish to have support from The Laura Centre within these working practices. I am aware that I can ask for more information about any relevant policy whenever I want. I also understand that this is a mutual process and will be continually reviewed by myself/us, my child/ren (if appropriate) and the counsellor. I also understand that I can finish therapy at any time. Please be aware that you are completing this part of the form on behalf of all those entered on the form.
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I agree
Should you not agree please close this form and contact our office with your concerns
By checking the box below you are agreeing to the terms of the contract as laid out above and confirming that the information you have submitted is, to the best of your knowledge, correct. You will not be able to submit the form unless this box is checked.
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I agree
If you do not agree then please close this form and contact our offices with your concerns
If signing on behalf of (a) child/ren- please confirm that you are the parent/legal guardian of the child(dren) whose details have been entered onto this form
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I am the parent/legal guardian
Notes and other information (optional)
please enter any other information that you think may be relevant (optional)
Copy of form.
When you click on the Submit button you should receive a copy of the form sent to the email address stated on this form. If you do not receive a copy please contact our office and we will forward one to you.
Email
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