Spectra SWP Counselling Registration Form

Please verify that you are human*
Spectra's counselling service is confidential. This means we will not share any information you provided here, or your prefession, with a third party, e.g. your GP, unless you told us to. We keep our client data for 7 years. If your counselling application is unsuccesful, we will remove your data after 6 months. While we have your data, there might be circumstances when we have to share information about you. These could be:
- when there is a serious concern for your or someone else’s safety, particularly if a child is at risk of serious harm;
- when there is a legal obligation relating to your involvement in, or knowledge of, a serious crime;
- when a court order requests information about you;
- when it is essential to prevent a serious and imminent threat to either public health or national security.
We will always seek your consent before any disclosure.

If you need any support to complete this form, please contact us via counselling@spectra-london.org.uk.

* Required.
Have you used any of these Spectra services in the past?*

NoneAdvocacyPeer MentoringTrans/Non-binary Social GroupCounsellingSex Worker SupportOther
This was within the past 12 months*

YesNo
- First Name*
- Last Name*
- Preferred Name
- Your Pronouns*
  
  She/herHe/himMazThey/themZie/hirOther
- Date of Birth*
  
  DayMonthYear
  Date
- Your Borough*
- Do you live, work, or socialise in any London borough(s) below*
  
  LambethLewishamRichmondSouthwarkWandsworthNone of these
- Note
- Ethnic Origin*
  
  White BritishWhite IrishWhite Western EuropeanWhite Eastern EuropeanWhite: Other White BackgroundAsian BritishAsian IndianAsian PakistaniAsian BangladeshiAsian: Other Asian BackgroundBlack BritishBlack AfricanBlack CaribbeanBlack: Other Black BackgroundMixed: White and Black AfricanMixed: White and Black CaribbeanMixed: White and AsianMixed: Other Mixed BackgroundArabChineseLatin/ South AmericanDo not wish to stateOther
- Gender Identity *
  
  AgenderFluidMan/MaleNon conformingNon-BinaryQueerQuestioningTransfeminineTransmasculineWoman/FemaleNot sureDo not wish to stateOther
- Is your current gender identity same as you were assigned at birth?*
  
  YesNo
- Sexual Orientation*
  
  AsexualBisexualDemisexualGayGraysexual/GreysexualLesbianPansexualQueerQuestioningStraightNot sureDo not wish to stateOther
- 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
  
  YesNo
- Text
  
  YesNo
- Voicemail
  
  YesNo
- Email
  
  YesNo
- 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?
  
  YesNo
- 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 contact our service?*
- How do you hope counselling might help?*
- Are you currently recieving or waiting for any psychological support 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?
  
  Alex case advocacyAlex online wellbeing sessionsAlex peer support groupCreative therapy group
- 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**
  
  Face to faceOnlinePhone
- I would like to subscribe to your newsletter*
  
  YesNo
- I agree with Spectra's privacy policy*
  
  YesNo
- You can find Spectra's private policy here.
- Should be Empty: