COUNSELLING CONSENT FORM
MH Ultimate Wellbeing – Coaching & Wellbeing Support
CONSENT FORM
1. Purpose of Coaching & Wellbeing Support Coaching is a confidential professional relationship that supports you to explore your goals, increase self-awareness, and make positive changes. We may use techniques such as psychoanalytic-informed reflection, NLP, and coaching tools. Coaching is not therapy, or medical treatment. If clinical support is needed, I will support you to access appropriate services.
2. Cancellation Policy If you need to cancel or reschedule an appointment (including workshops), please notify MH Ultimate Wellbeing – Coaching & Wellbeing Support at least 24 hours in advance. Less than 24 hours’ notice: 50% of the session fee. Same-day cancellations or no-shows: 100% of the session fee. For appointments on Monday, please cancel by the preceding Friday.
3. Confidentiality Everything we discuss is private. I will not share your information with anyone else without your permission, except in the following situations:
• If I believe you or someone else is at serious risk of harm.
• If I suspect abuse of a child, elderly person, or vulnerable adult.
• If I am legally required to disclose information by a court or law.
• In rare cases, if I have serious concerns about your well-being and need to take steps to protect you. In these situations, only the minimum necessary information will be shared.
4. Online Sessions & Privacy If we have sessions online (for example, on Zoom or Google Meet), I will keep them private, but because these services are run by other companies, I cannot guarantee 100% privacy. By joining online sessions, you understand and accept this small risk.
5. Session Reports I may write a short report after your session about your feelings, emotions, and progress. These reports are for professional use only and are not a word-for-word record of what you said. Reports are stored safely and retained for up to 5 years, then securely destroyed. You understand that the report reflects my professional view of the session and may not match exactly how you remember it.
6. Data Protection (UK & Ireland)
MH Ultimate Wellbeing – Coaching & Wellbeing Support complies with applicable data protection laws, including the UK GDPR and Data Protection Act 2018 (UK), and the General Data Protection Regulation (EU) and Data Protection Act 2018 (Ireland).
Your personal information will only be used for coaching purposes or shared with your written consent, except as outlined under “Confidentiality.”
7. Professional Background
I am a psychoanalytically informed coach and practitioner. I am currently in my final year of a BSc in Criminology and Psychology at Swansea University. My coaching practice is informed by psychological theory; however, I do not provide clinical psychological services or mental health treatment.
8. Scope & Limitations
This service provides coaching and wellbeing support only. It does not constitute medical, psychological, psychiatric, or therapeutic diagnosis or treatment of any mental health condition.
If you are experiencing severe distress, suicidal thoughts, or symptoms of mental illness, you should seek immediate support from your GP or appropriate public health services, including the HSE (Ireland) or NHS (UK).
If appropriate, I can assist in signposting or referring you to relevant professional or emergency services.
9. Emergency Guidance
If you are in immediate danger or experiencing a crisis, please call 999 (UK) or 112 / 999 (Ireland), or attend your nearest Accident & Emergency (A&E) Department.
For urgent mental health support:
• In Wales, contact NHS Wales urgent mental health services.
• In Ireland, contact your GP, local HSE mental health services, or your nearest Emergency Department.
• You can also contact Samaritans (UK & Ireland) on 116 123 (free, 24/7).
10. Consent
By signing this agreement, you confirm that:
• You understand the purpose, process, expectations, potential benefits, and limitations of coaching and wellbeing support.
• You understand the confidentiality policy, data protection policy, emergency procedures, and the limitations of online sessions.
• You understand that coaching is not therapy, counselling, psychiatric, or medical treatment.
• You voluntarily consent to participate in coaching sessions.
• You consent to the collection, use, and secure storage of your personal data in accordance with applicable data protection laws.
• You understand that you may withdraw your consent at any time, subject to reasonable notice and any legal or safeguarding obligations.
Client Signature: _______________________________________________________Date: ___________
Client Name (printed): __________________________________________________
Counsellor Signature: __________________________________________________ Date: ____________
Counsellor Name (printed): _____________________________________________