We need to record your details which we will hold to enable us to deliver a service to you. By completing this form you are indicating your consent. You have the right at any time in the future to withdraw your consent. We confirm that your information will not be passed to any third parties.

Name:*

Address:

Date of Birth/age:

Gender:

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Email:*

Telephone/mobile:

Permission to leave messages: Yes/No

Doctor's name and address:

Please briefly indicate your reason for seeking counselling:

Have you had counselling before? Yes/No:

Are you currently on any medication?

When would you be available? At least two choices if possible.

If you require assistance with regards to mobility or have a visual or other impairment please let us know.

What form would you like counselling to take? Face-to-face or Online

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All personal information is processed according to the Data Protection Act 1998. Registration No. Z3101619