Online counselling form

First name *

Last name *

Phone number *

Enter a UK phone number (e.g. 0121 234 5678) or a number with an international call prefix.

Can we leave a message on your voicemail? *

Yes

No

Email address for counselling *

Main email address (if different) (optional)

Please indicate how you would like to know if there needs to be a cancellation?: *

Phone

Email

Date of birth *

Day

Month

Year

Address line 1 *

Address line 2 (optional)

Town/City *

Country (optional)

Postcode *

Preferred format for Counselling *

Telephone

Video Conferencing

Email

GP/Surgery name (optional)

By providing us with your GP's details, you give us permission to contact them in the event of an emergency.

GP/surgery phone number (optional)

Enter a UK phone number (e.g. 0121 234 5678) or a number with an international call prefix.

GP's surgery address line 1 (optional)

GP's surgery address line 2 (optional)

GP's town/city (optional)

GP's country (optional)

GP's postcode (optional)

What brings you to sight loss counselling? *

Any other issue? *

What sight condition do you have? *

What other support do you feel you have at the moment? If yes, please specify:

Are you on any medication? (Please list): *

Have you previously felt like harming yourself or taking your life? : If yes please provide further details:

Do you currently feel like harming yourself or taking your life? If yes please provide further details:

What would you like to change by having online sight loss counselling? *

When are you available? e.g. Tuesday afternoons after 2pm and Friday mornings *

We offer sessions between 9am-5pm, Monday to Friday.

Electronic signature *

Please type your name in the box below

Date *

Day

Month

Year

Appearance

Appearance

Online counselling form

First name *

Last name *

Phone number *

Email address for counselling *

Main email address (if different) (optional)

Home address

Address line 1 *

Address line 2 (optional)

Town/City *

Country (optional)

Postcode *

Your GP's contact details

GP/Surgery name (optional)

GP/surgery phone number (optional)

GP's surgery address

GP's surgery address line 1 (optional)

GP's surgery address line 2 (optional)

GP's town/city (optional)

GP's country (optional)

GP's postcode (optional)

Just a few questions

What brings you to sight loss counselling? *

Any other issue? *

What sight condition do you have? *

What other support do you feel you have at the moment? If yes, please specify:

Are you on any medication? (Please list): *

Have you previously felt like harming yourself or taking your life? : If yes please provide further details:

Do you currently feel like harming yourself or taking your life? If yes please provide further details:

What would you like to change by having online sight loss counselling? *

Your availability

When are you available? e.g. Tuesday afternoons after 2pm and Friday mornings *

Electronic signature *

Online counselling form

First name *

Last name *

Phone number *

Email address for counselling *

Main email address (if different) (optional)

Home address

Address line 1 *

Address line 2 (optional)

Town/City *

Country (optional)

Postcode *

Your GP's contact details

GP/Surgery name (optional)

GP/surgery phone number (optional)

GP's surgery address

GP's surgery address line 1 (optional)

GP's surgery address line 2 (optional)

GP's town/city (optional)

GP's country (optional)

GP's postcode (optional)

Just a few questions

What brings you to sight loss counselling? *

Any other issue? *

What sight condition do you have? *

What other support do you feel you have at the moment? *If yes, please specify: *

Are you on any medication? (Please list): *

Have you previously felt like harming yourself or taking your life? : *If yes please provide further details: *

Do you currently feel like harming yourself or taking your life? *If yes please provide further details: *

What would you like to change by having online sight loss counselling? *

Your availability

When are you available? e.g. Tuesday afternoons after 2pm and Friday mornings *

Electronic signature *

Can we keep you up to date?

What other support do you feel you have at the moment? If yes, please specify:

Have you previously felt like harming yourself or taking your life? : If yes please provide further details:

Do you currently feel like harming yourself or taking your life? If yes please provide further details: