mid-priced-self-referral-form

First Name

Last Name

Age (must be 18 or over)

Email:

Phone:

Gender

Preferences

Female Counsellor

Male Counsellor

LGBTQ+ aware

Don't Mind

Please outline what your issues are:

I would prefer sessions to be:

Online

Face to Face

Phone

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 newly qualified counsellor to help me with

Opt-In

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