Counselling Service Centre Luton Appointment Booking Consent Form

Client Information:

Full Name:


Date of Birth:




Phone Number:


Email Address:

Appointment Details:

Preferred Appointment Date:


Preferred Appointment Time:


Type of Appointment (In-person/Virtual):

Consent to Counselling Services:
I, the undersigned, consent to participate in counselling services offered by the Counselling Service Centre Luton. I understand and agree to the following:

1. Confidentiality:
I acknowledge that the information shared during counselling sessions will be kept confidential, with the exceptions outlined in the confidentiality policy provided by the Counselling Service Centre Luton.

2. Appointment Cancellation Policy:
I understand that if I need to cancel or reschedule an appointment, I must provide at least 24 hours’ notice. Failure to do so may result in a cancellation fee.

3. Virtual Counselling Considerations:
If I choose virtual counselling, I am responsible for ensuring the privacy and security of my communication environment during the session.

4.Payment and Fees:
I acknowledge and understand the fees associated with counselling services at the Counselling Service Centre Luton. Payment is expected at the time of the appointment unless other arrangements have been made.

5. Emergency Situations:
In the event of an emergency or if I pose a risk to myself or others, the counsellor may need to breach confidentiality to ensure safety. I understand and accept this condition.

Client Signature:




Counselling Service Centre Representative:
I confirm that the client has been provided with information regarding our policies, including confidentiality, cancellation, and fees. I am available to address any questions or concerns.

Counselling Centre Representative Signature:



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