Secure Counselling Request Form
Secure Counselling Request Form
Title
Forename *
Your answer
Surname *
Your answer
How do you identify
If prefer to self describe please specify
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address *
Your answer
Postcode *
Your answer
Home Phone
Your answer
Mobile Phone Number *
Your answer
Email
Your answer
Can we contact you by mobile? *
Is it ok to leave a message? *
Our phone will display as a private number
Is it ok to send text reminders for appointments?
Do you consider that you have any physical disability that could affect counselling?
Counsellor Preference *
GP Name
Your answer
GP Address
Your answer
What is your preferred location for counselling? *
What times are you available to attend counselling? *
Required
Have you attended Nexus NI before? *
How did you find out about Nexus NI?
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