In order for you to be added to our waiting list, we need to take some details from you and ask some questions about your mental health

This information is collected securely with the sole purpose of adding you to our waiting list and ensuring that you see a counsellor who meets your needs.

Please complete the following information

speach-bubbles

Enquiry Form

Name: *

Age: *

Tel. Number: *

Email: *

Ethnicity *

Area you live: *

Where would you prefer to go for your counselling: *

1st Choice

2nd Choice

Any of the sites

Flexibility to come and see us. Please state when you can come and see us for example if you could come at any time please state flexible. If you can come and see us any time on Mondays, then please state Mondays only. Please tell us as much as you think would be helpful. Please try and be as flexible (but realistic for yourself) as possible so that we can try and fit you in for an appointment as quickly as possible.

Indicate here: *

How did you hear about us? *



Continue