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Counselling – initial form
Counselling Self Referral Form
Date of Birth
Date Format: DD slash MM slash YYYY
Address Line 2
Can we send letters to this address?
We will assume we can email you about counselling to this address.
Can we leave a message on your phone?
Do you have any additional support requirements?
Please give further details
What days/times are you available for us to arrange a one-off consultation appointment with you?
The more flexibility you have, the quicker you can be seen.
What days/times are you available to attend for regular weekly sessions? The more flexibility you have, the quicker you can be seen
During the current covid19 situation, what type of counselling would you prefer
Wait until face to face is an option
How did you hear about Bridge Counselling? Please select an option...
West Calder Community Development Trust
Please tell us about any particular access requirements:
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