Enquiry Form
To help us assess which service is most suitable for you, please complete the form below as fully as possible.
Full Name
*
First Name
Last Name
Date enquired
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Age
*
Please Select
18-24
25-34
35-44
45-54
55-64
65+
Gender
Please Select
Male
Female
Other
Prefer not to say
Area you live in
*
Profession
Email Address
*
example@example.com
Telephone Number
*
-
Area Code
Phone Number
Address
What challenges are you currently facing in your life and/or business at the moment that you would like support with?
*
Please tell us what you are hoping to get out of the support?
*
Have you received support previously?
*
Yes
No
Which services are you particularly interested in?
*
Counselling/Psychotherapy
Couples Counselling
Single Session Therapy (SST)
Other
Would you prefer your sessions to be...
*
In person (at our therapy rooms in either Ednaston Park or Swadlincote)
Online (via Zoom)
A mixture of the two
Don't mind
What availability do you have for the support? Please tick the times that you are available.
*
Rows
9-12pm
12-3pm
3-5pm
5-9pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Is there anything else regarding your availability that would be helpful for us to know?
How did you hear about us?
*
Word of mouth
Recommendation from a previous client
You have been a client before
Through your employer
Event/workshop
Counselling Directory
Other
Please tick if you are being referred through your employer.
Employer
Private Healthcare Insurance
Other
Do you have any diagnosed mental health conditions?
Yes
No
If yes, please specify
I consent to the collection and processing of my data for the purpose of this enquiry
*
I agree
Submit
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