Spectra Trans Counselling Registration Form

Please verify that you are human
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Due to very high demand, we have temporarily paused new referrals for trans counselling to manage our current wait times. The waiting list will open again shortly. Please check back soon for updates.
Have you used any of these Spectra services in the past?

Other
This was within the past 12 months
- First Name
- Last Name
- Preferred Name
- Your Pronouns
  
  Other
- Date of Birth
  
  DayMonthYear
  2 digit day, 2 digit month, 4 digit yearDate
- Your Borough
- Ethnic Origin
  
  Other
- Gender Identity
  
  Other
- Is your current gender identity same as you were assigned at birth?
- Sexual Orientation
  
  Other
- Any disability/neurodiversity?
- Please provide more details if so.
- What support, if any, do you need to access this service?
- Have you been referred to a gender clinic?
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (+44) 000-0000-0000.
- In order to arrange appointments we will contact you by phone and email. If you prefer not to receive communication by any of these methods, please change the appropriate boxes.
- Phone call
- Text
- Voicemail
- Email
- Address
- Other communication preferences
- GP Name
  Please put N/A if you don't have one.
- GP Contact Details
  Please put N/A if you don't have one.
- Is your GP aware of your gender identity?
- Name you use with your GP
  If different from above.
- Emergency contact name
- Emergency contact phone number
  Please enter a valid phone number.Format: (+44) 000-0000-0000.
- Emergency contact email
  example@example.com
- Relationship to you
- How did you find us?
- What has led you to apply for this service?
- How do you hope counselling might help?
- Are you currently waiting for any service elsewhere?
- In order for us to be mindful of any conflict of interest please could you tell us if you know any staff at Spectra, are in a close relationship with someone who has applied to/ is receiving counselling from Spectra. Or if you are receiving counselling elsewhere.
- Are you interested with any other Spectra services?
- Share with THA
- Suicidal thoughts
- Suicide attempt
- Self harm
- Problematic use of alcohol/drugs
- Abuse
- Assault
- Trauma
- Threatened or intimidated
- Hate crime
- Discrimination
- Problems with eating
- Homelessness/Housing
- Bereavement/Loss
- Self-esteem
- Relationship difficulties
- Anything else?
- Please indicate your preferable time and day(s) of the week for counselling sessions.
  For example: 1pm-7pm, Monday to Friday; 4pm-7pm, Wednesday
- Preferred Platforms*
- For face to face service, please let us know your preference for location
- I would like to subscribe to your newsletter
- I agree with Spectra's privacy policy
- You can find Spectra's private policy here.
- Should be Empty: