Couples Therapy with

Liesel Greyling

Integrative Psychotherapist

Please complete the following forms. Please note that both partners need to sign the consent form together, but complete the couples assessment independently.

    Couple’s Intake & Assessment Form

    The purpose of this document is to help us explore your current needs, your background, and your goals for therapy. By gathering this information before we agree to a session, we can build a clear picture of what you are experiencing and ensure that online psychotherapy is the right and safe space for you, and that I have the necessary expertise to help you achieve your specific couples' therapy goals.

    What Happens to Your Completed Form:
    All information provided in this form is strictly confidential. Your data is handled and securely stored in full compliance with UK Data Protection law (UK GDPR) and my registration with the Information Commissioner's Office (ICO). It will not be shared with anyone without your explicit consent, except under the rare legal and safeguarding limits outlined in our Individual Client Therapy Agreement. Should you choose not to start therapy with me, I will permanently and securely delete this form.
    Section A: Administrative and Online Safety
    Is Online Therapy Safe and Practical for You?
    Please check all that apply to your current environment:
    Section B: About You as an Individual

    (This section helps understand individual backgrounds, personal mental health, and caregiver history)

    What Is Going on For You Personally Right Now?
    Please select which represent core personal challenges bringing you into therapy at this time:
    Are You Struggling Specifically with Anxiety, Depression, Addiction, or Suicidality?
    Anxiety Symptoms:
    Depression Symptoms:
    Addiction & Substance Use:
    Suicidality, Self-Harm & Safeguarding:
    Emergency & Crisis Disclaimer:
    This private online practice does not provide an immediate emergency or crisis intervention service. If you feel unsafe, are in immediate danger of hurting yourself, or are experiencing a severe mental health crisis, please contact your local emergency services immediately by calling 999 or visiting your nearest Accident & Emergency (A&E) department. You can also call the NHS medical line on 111, contact your local GP surgery, or call the Samaritans on 116 123.
    Do You Take Prescribed Psychotropic Medication?
    Please check any medications currently prescribed to manage mental health:
    What Were Your Childhood Caregiver Experiences?
    Reflecting on your childhood, tick any items that represent your felt experience growing up:
    What Were Your Prior Adult Relational Dynamics Like?
    Reflecting on your romantic history prior to your current partnership, tick any patterns that apply:
    Do You Have any Prior Therapy Experience?
    What Do You Want from Me as Your Therapist?
    What style of therapy do you feel would suit you best? (Check all that apply):
    Section C: About the Couple
    What Is Your Story and Relational Journey?
    How Would You Rate Your Partnership Satisfaction?
    0 = Not at all satisfied10 = Extremely satisfied
    What Do You Consider to be the Core Relationship Focus Areas?
    Please select any areas that apply to your current situation:
    What Stressful Life Events and External Pressures Are in the Mix?
    Please log any external stressors currently acting upon you or your relationship dynamic:
    What Are the Current Conflict & Relational Reactivity Loops?
    When tension, distance, or a disagreement arises between you and your partner right now, how do you tend to respond? (Tick all that apply):
    Are There Any Individual Safety & Safeguarding Concerns?
    As part of establishing a safe, ethical clinical framework, please answer the following accurately:
    Couples Psychotherapy Agreement & Informed Consent

    This document outlines the professional, ethical, and legal frameworks that inform my couples therapy practice and our therapeutic relationship. Please read the information, fill in the required information and provide the consent requested within. As couples therapy fundamentally differs from individual therapy, both partners must independently agree to and sign these terms before our clinical work begins.

    The Relationship as the Primary Client

    In couples therapy, the individual partners are not considered the primary client. The primary client is the relationship itself. My professional role is to serve as an objective, neutral facilitator to support your relationship's health, communication, and growth. I do not act as an advocate, judge, or ally for either individual partner.

    The 'No Secrets' Policy

    To provide both of you with a safe space that is entirely transparent, and that serves the relationship, I adopt a 'No Secrets' Policy. This means that any information shared with me outside of joint couples sessions—whether via individual emails, text messages, phone calls, or individual breakout sessions—cannot be kept confidential from your partner if it directly impacts the relational work.

    In line with this approach, if you share information with me that your partner does not know and that impedes our couples work, my role would be to support and encourage you to bring this information into our joint sessions. If you refuse to share a critical piece of information that actively undermines the therapy (such as an ongoing, unrevealed affair), I reserve the right to suspend or terminate the couples therapy immediately.

    Both of You Need to be Present

    As I provide a safe and neutral clinical space, for couples sessions to go ahead, both of you need to be present, unless we have an agreed individual session booked. Individual sessions – referred to here as 'break-out sessions' are planned sessions with each of you individually, to either a) obtain your personal journey right at the beginning of our therapy together or intermittently scheduled to check-in with each of you, as the need arises. Importantly, these are equal for each of you in terms of frequency and duration.

    What You Can Expect: Session Logistics & the Online Framework

    Format & Platform:

    All sessions are conducted online via a secure, GDPR-compliant Zoom platform. You will receive a unique access link prior to each scheduled appointment.

    Session Duration:

    The standard couple's therapy session is 75 minutes long.

    Session Frequency:

    For new clients, weekly sessions are advised for at least 6 consecutive weeks (where possible), to ensure that there is sufficient time between sessions for processing but not too big of a gap to interrupt the therapeutic process. If you are thinking of having less sessions than this, please use the contact us form before we get started to discuss this and see if it could foreseeably be viable.

    Ensuring a Safe Therapeutic Environment:

    It is important for us to access the session from a private, quiet space. To maintain confidentiality, you are requested not to attend sessions from public spaces, or in spaces where children or relatives can overhear the session. Neither partner may record any portion of our therapeutic sessions via software, audio devices, or video capture tools.

    Technical Disruptions:

    In the unlikely event that our connection drops, we will first attempt to reconnect via the platform. Should the platform fail completely, I will call your mobile number to mutually decide if and how to complete the session or to reschedule.

    Fees, Payments & Cancellation Policy

    Session Fees:

    There are variances in the couples therapy fees, depending on type of session, and the session frequency and duration:

    Duration Frequency Description / Indication Fee
    75 min Couples Session Weekly Recommended for:
    - Start-up Couple's therapy
    £85.00
    Bi-Monthly Minimum requirement for:
    - Start-up Couple's therapy
    - Stabilised Couples
    £95.00
    Sessional Once a month or less for:
    - Couples nearing the end of Couple's Therapy
    £105.00
    60 min Break-out Sessions As Required Used for:
    - Initial Individual Background Information
    - As needed in between Couples Therapy
    £65.00
    + 15 minutes Ad Hoc Additional time of up to 15 minutes either because:
    - The topic in session requires more time
    - The additional time is requested and pre-booked by the couple
    +£25.00
    Payment Terms:

    To secure your booking, payments should be made via bank transfer at the time of the booking or at least 48 hours before the scheduled session time. Sessions will not be considered to be confirmed until the payment is received, and without a payment reflecting 48 hours before the scheduled session, the slot may be given to another couple at this time.

    Cancellation Policy:

    BSpoke Therapy Practice operates a strict 24-hour cancellation policy. If you cancel or request to reschedule an appointment with less than 24 hours' notice, or if you miss a session entirely, the full session fee remains payable, as this slot cannot be made available to other clients.

    Confidentiality & Legal Limits (UK Based Psychotherapy)

    BSpoke Therapy Practice is registered in the UK. As such, you will be accessing UK based Psychotherapy, meaning that the ethical and professional framework that informs my work is the British Association for Counselling and Psychotherapy (BACP) and is governed by UK law. You can access and review the BACP ethical and professional framework by following this link: BACP Ethical Framework. From within these frameworks, your privacy is fundamental. All information shared within our sessions is strictly confidential. However, limitations to confidentiality do exist in terms of the following exceptional circumstances:

    Risk of Harm:

    I have a duty of care to yourself and others. Therefore, if I assess that there is a severe, imminent risk of serious harm to yourself or to another identifiable person, I will need to breach confidentiality.

    Legal Mandates:

    If I am legally compelled to disclose information, such as by a court order or under UK legislation concerning terrorism, drug trafficking, or money laundering, confidentiality will need to be breached.

    Safeguarding:

    If a disclosure is made regarding the ongoing abuse or neglect of a child or a vulnerable adult, I am unable to keep this in confidence.

    Professional Supervision:

    In line with my BACP professional and ethical standards, I regularly discuss my client work anonymously with a qualified Clinical Supervisor. Should your case be discussed, your identity is never revealed during Supervision sessions.

    Data Protection & GDPR Compliance

    Data Controller:

    I operate as the Data Controller for your personal information. Therefore, I am personally registered with the Information Commissioner's Office (ICO).

    Record Keeping:

    I keep brief, anonymised client notes in accordance with UK law and ethical frameworks. These are stored securely and kept for 3 years after therapy ends, after which they are permanently destroyed.

    Communication & Crisis Support

    Between Session Contact:

    Clients can contact me for administrative purposes (e.g., booking or altering appointments). Please note that I am not able to provide therapeutic support or crisis management via messaging channels. Phone details are reserved for us communicating in the event of a technical issue or a short-notice unavailability at the time of a session.

    Crisis Management:

    Unfortunately, I am not able to provide an emergency crisis service. If you experience an acute mental health crisis or require immediate medical attention between sessions, please contact:

    • Your local NHS GP surgery.
    • The NHS 111 service (or 999 in a life-threatening emergency).
    • The Samaritans by calling 116 123.

    Professional Standards, Ending Therapy & Consent

    Ethical Adherence:

    I am a registered member of the British Association for Counselling and Psychotherapy (BACP) and abide by their Ethical Framework for Good Practice.

    Complaints:

    If you have any concerns regarding our work together, please discuss them with me first. If the matter cannot be resolved, you can file a formal complaint directly with my professional body.

    Planned Ending:

    You have the right to end therapy at any time. To ensure a safe and psychologically grounded ending, I strongly recommend giving at least one week's notice so we can hold a dedicated closing session.

    Legal Proceedings, Court Attendance, and Release of Records

    Joint Record Protection:

    Clinical notes taken during couples sessions represent a joint record under UK Data Protection law (UK GDPR). Because the file belongs to the relationship, notes will never be released to any third party, solicitor, or insurance provider unless BOTH partners provide independent, signed written consent. Neither partner can unilaterally authorize the release of joint couples files.

    Production of Notes and Records:

    In accordance with UK data protection laws, therapy notes will not be disclosed to any third party without your explicit written consent, unless I am legally compelled to do so by a formal Court Order or Production Order issued by a judge.

    Witness Summons and Court Appearance:

    By agreeing to these terms, you explicitly acknowledge that couples therapy is intended solely for relational healing, not for legal or adversarial leverage. You agree not to involve the therapist or our clinical records in any court proceedings, including civil litigation, divorce disputes, asset distribution, or child custody evaluations. If I am legally served with a Witness Summons requiring me to attend court or a tribunal regarding our therapeutic work, my role is strictly restricted to that of a "witness of fact" (confirming dates of attendance and factual session occurrences). I am not an expert witness and will not provide clinical opinions to a court.

    Legal Fees and Costs:

    Because legal proceedings compromise the therapeutic dynamic and require extensive administration, you agree to jointly reimburse all professional time associated with any legal requests originating from your case. This includes record reviews, preparation, consultation, and court attendance. This time is billed outside standard therapy rates at £150 per hour.

    Domestic Abuse and Safeguarding Policies

    Couples therapy requires an environment of basic safety and mutual equity. If during our initial assessment or ongoing therapy it becomes apparent that active domestic abuse, physical violence, severe intimidation, or coercive control is present, couples therapy will be safely suspended. Couples work is clinically contraindicated and unsafe in these environments. In such cases, I will work with you to safely pivot to individual signposting or specialized support services.

    Keeping You Safe During Sessions

    As mentioned above, in the event of risk to yourself, either by means of a mental health crisis or a medical emergency which becomes apparent during a session, I have a duty of care towards you. For this purpose, please confirm that you have filled in your GP and Emergency Contact details in Section A of the assessment form.

    Client Consent & Agreement Confirmation

    By filling out the details below, I confirm that I am aware that I am accessing UK based Couples Therapy, and that I have read and understood the terms outlined in this Couples Therapy Agreement & Informed Consent form. I further confirm that I voluntarily consent to engage in online couples therapy under these conditions and allow my therapist to make use of the details I provided if required for the purposes outlined within.

    Partner A Consent
    Partner B Consent

    Write Your Message

    All completed forms are emailed directly to the therapist and not stored on a cloud or on the website. A copy is also emailed to you.

    Thank You for Completing the Assessment!

    Your information has been securely submitted. I will review your responses and reach out to you shortly to discuss the next steps for your couple’s therapy sessions.

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