Counselling – initial form – Bridge Community Project

The Bridge Counselling Service is currently open for new referrals. If you would like to arrange an initial consultation session we require you to complete the following form. All information you supply will be treated in strict confidence, as detailed in our Privacy Policy, but you do need to consent to us holding and processing your data. Please note that completing the form is not a guarantee of counselling but it will allow us to move towards the allocation of an Initial consultation where we can have a discussion with you about whether counselling would be a good way forward for you at this time. Once received we will be in contact with a potential date for the Initial consultation.

Name*

First Last

Gender*

Male
Female

Date of Birth*

Address*

Street Address Address Line 2 City Post Code

Can we send letters to this address?*

Yes
No

Phone*

Email*

We will assume we can email you about counselling to this address.

Preferred Communication*

Phone
email

Can we leave a message on your phone?*

Yes
No

Do you have any additional support requirements?*

Yes
No

Please give further details

Initial Consultation

What days/times are you available for us to arrange a one-off consultation appointment with you?*

Wednesday 1pm
Thursday 7pm
Friday 10.45

The more flexibility you have, the quicker you can be seen.

Regular Appointments

What days/times are you available to attend for regular weekly sessions? The more flexibility you have, the quicker you can be seen*

Monday Morning
Monday Afternoon
Tuesday Morning
Wednesday Afternoon
Thursday Evening
Friday Daytime

Counselling Options

During the current covid19 situation, what type of counselling would you prefer*

Zoom (video)
Phone
Wait until face to face is an option

How did you hear about Bridge Counselling? Please select an option...*

GP
Wellbeing Hub
West Calder Community Development Trust
Friend
Web Search
Been before
Employer

Please tell us about any particular access requirements:

*

Accept Data Protection Policy

We are committed to keeping your data safe and sound. Find out how your data will be used by reading our privacy policy. If you are happy to continue, please check the box above.

Counselling Self Referral Form