Organisational Client Enquiry Form

Thank you for getting in touch with us. To proceed with a referral, we will need to collect some additional information from you:

Name *

First

Last

Date of Birth *

Your preferred Pronouns *

Address Line 1 *

Address Line 2 *

Postcode *

Name of Employer/site working at *

How are you seeking sessions? Please select all that apply. *

*Please note that we offer face to face in limited locations, and there may be a waiting list for such sessions.

If your preference is face to face, how far you would be able to travel to see a counsellor:

Your availability for sessions? *

Greater flexibility improves our ability to match you with a counsellor.

Do you need any adjustments for your sessions?

Are there any counsellor genders you would prefer not to work with?

Are you working at the moment? If yes, please provide a brief outline of your job: *

A brief explanation of what you are seeking counselling for: *

1 you you

Have you had counselling previously? If so, when and could you share a little about what it was for? *

Do you have a mental health diagnosis? If so, can you let us have details, including what other support you might be receiving: *