Self-referral

Self-referral form for free counselling. (Currently, due to COVID-19 restrictions, counselling is via phone or Zoom.)

Title: *

First name: *

Last name: *

Address: *

Postcode: *

Date of Birth (Please write as: dd/mm/yyyy) *

Email *

Mobile Phone Number *

Landline Number (If you have one)

Is it ok to leave messages on your mobile? (Pick one) *

YesNo

Is it ok to leave SMS/text messages on your mobile? (Pick one) *

YesNo

Is it ok to send you web forms? (Pick one) *

YesNo

Are you a government worker, e.g. NHS, Council or involved in providing goods and services? *

YesNo

What is the reason for your self referral - What do you need help with, e.g stress, anxiety, loss, depression, other? *