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Counselling – initial form
Counselling – initial form
admin
2018-07-20T11:49:58+00:00
Counselling Self Referral Form
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
*
Date Format: DD slash MM slash YYYY
Address
*
Street Address
Address Line 2
City
Post Code
Can we send letters to this address?
*
Yes
No
Phone
*
Mobile
*
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?
*
Monday 1pm
Tuesday 9.15pm
Thursday 7pm
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
Tuesday Evening
Thursday Evening
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.
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