affordable-self-referral-form

First Name

Last Name

Age (must be 18 or over)

Email:

Phone:

Gender

Preferences

Female Counsellor

Male Counsellor

Don't mind

Please outline what your issues are:

Options

Face to Face

Online (limited not guaranteed)

Convenient days & times

Please tick if these statements are correct:

I am currently not receiving help from any other mental health institutions

I think my issues are appropriate for a student to help me with

Venue Preference

37 Clarence Street, Southend, SS1 1BH

327 Bridgwater Drive, Westcliff, SS0 0HA

Either venue is fine

Opt-In

By checking, I agree to share my details with Counselling on Sea.