Online counselling form

Please fill in the form below to request a session 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

Fields marked * are required.

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

Email address for counselling *

Confirm email address (optional)

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

Phone

Text message

Date of birth * We can offer counselling to clients aged 11 and over

Day

Month

Year

Home address

Address line 1 *

Address line 2 (optional)

Town/City *

Country (optional)

Postcode *

Preferred format for Counselling *

Telephone

Video Conferencing (Microsoft Teams)

Your GP's contact details

GP/Surgery name, phone number and address (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.

Emergency contact details/next of kin (optional)

Just a few questions

What brings you to sight loss counselling? *

Do you have any other support 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? *