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Counselling Request Form
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Counselling request
Title
*
Mr.
Mrs.
Miss.
Ms.
Other
First Name
*
Last Name
*
Age
*
Mobile Phone
*
Home Phone
Email Address
*
What sort of counselling are you looking for? (Select all that apply)
*
Online Counselling
In Person Counselling
Phone Counselling
When would you be available for counselling? (Select as many as you like)
*
Early Morning (7:30am - 9am)
Morning
Afternoon
Evening
When ringing you back is it ok for the counsellor to contact you directly?
*
Yes
No
Or, do you prefer we let you know the details of who we have organised for you first?
*
Yes
No
Please could you tell us briefly why you have been referred to us / why you would like counselling? This may help us in deciding which counsellor will be best for you to see, as some of them specialise in different areas.
*
Have you had counselling / therapy before?
*
Yes
No
If yes, please could you provide us with some further information : (e.g. when? how long?)
How did you hear about our counselling service?
Any additional notes?
Submit