1. Personal Details

Name(Required)
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Address(Required)

2. Contact Information

Preferred Contact Method(Required)

Is it safe to leave a voicemail?(Required)
Is it safe to send emails?(Required)
Is it safe to send text messages?(Required)

3. Emergency Contact

Do we have your permission to contact this person in an emergency if we are concerned about your immediate safety?(Required)

4. GP Details

5. Practical Information

Do you have any caring responsibilities?

Accessibility and Support Needs

Do you have any accessibility needs we should be aware of?(Required)

7. Health and Wellbeing Information

Are you currently taking any prescribed medication relevant to your emotional or mental wellbeing?(Required)
Have you previously received counselling, therapy, or mental health support?(Required)

8. Risk and Safety

9. Referral Information

10. Consent and Agreement

Privacy statement Please confirm that the information you have provided is accurate to the best of your knowledge. Your information will be stored securely and handled in line with data protection requirements. We will only share information where necessary for safety, legal, or safeguarding reasons.
Please confirm the following:(Required)
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Privacy Preference Center