Counselling Groups self-referral form

Please fill in the form below to register your interest in a group with one of our trained counsellors.

If you have any questions or have difficulty completing this form, please call our Helpline on 0303 123 9999 or email [email protected].

Fields marked * are required.

First name *

Last name *

Date of birth * These groups are for ages 18 and over only.

Day

Month

Year

Sight condition *

Reason for referral *

Please explain the circumstances which bring you to access this type of support.

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

Email address *

Confirm email address *

Address

Address line 1 *

Address line 2 (optional)

Town/City *

Country (optional)

Postcode *

Emergency contact details/next of kin (for emergencies only) (optional)

Your GP's contact details

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'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)

Your availability

Please let us know when you're available. *

We offer our counselling groups between 9am-5pm, Monday to Friday.

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Counselling Groups self-referral form

First name *

Last name *

Sight condition *

Reason for referral *

Phone number *

Email address *

Confirm email address *

Address

Address line 1 *

Address line 2 (optional)

Town/City *

Country (optional)

Postcode *

Emergency contact details/next of kin (for emergencies only) (optional)

Your GP's contact details

GP/Surgery name (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)

Your availability

Please let us know when you're available. *

Counselling Groups self-referral form

First name *

Last name *

Sight condition *

Reason for referral *

Phone number *

Email address *

Confirm email address *

Address

Address line 1 *

Address line 2 (optional)

Town/City *

Country (optional)

Postcode *

Emergency contact details/next of kin (for emergencies only) (optional)

Your GP's contact details

GP/Surgery name (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)

Your availability

Please let us know when you're available. *

Can we keep you up to date?