Title*

Preferred Pronoun*

First Name*

Surname*

Address line 1*

Address line 2

Address line 3

Town*

County*

Postcode*

Primary Email Address*

Primary Telephone No.

Emergency Telephone No.

Date of Birth*

Gender

Main Language*

Where did you hear about us?

What type of counselling are you requesting? *

Is anyone you know receiving counselling with us? If so please give details*

Do you have a disability or health condition which will require support from us for you to access counselling? *

Please select your health condition or disability from this list 

Please use this space to tell us of any support you might require to access our services (e.g. Large Print documents, ground floor access, disabled toilet, child changing facilities, etc.)

GP Surgery

Please let us know if there are any specific requirements to us contacting you (e.g.. work schedule, textphone, call screening etc.) 

Please indicate times, days and dates you would be available or unavailable for counselling. Please try to be as flexible as possible*

By submitting this form, you consent to Marches Counselling Service collecting and processing your personal data for the purpose of providing counselling services and managing your therapeutic journey. You can withdraw your consent at any time by contacting us via email at admin@marchescounselling.org or by calling 01432 279906. For more information on how we handle your data, please see our Privacy Policy which can be found following the link below.*