About you

First name*

Last name*

Date of birth*

Gender*

Other gender

Contact details

Phone number*

We will only use this to contact you about the service you are requesting.

How can we use this phone number?

Text messages

Phone calls

Leave messages (voicemail)

Email address

We will only use this to get in touch about your referral.

Can we send emails?

Yes

Address*

Please note, your postal address is required in case of emergency during your support sessions. In exceptional circumstances we may be required to call emergency services to your home. Your counsellor/support worker would only do this if they believed that there was immediate risk of harm to you or someone else at your home.

Town*

Postcode*

Can we send letters to this address?

Yes

Preferred contact method

Best time to contact

Your GP

Please note, your GP details are required in case we have serious concerns for your health and wellbeing during your programme of support. In exceptional circumstances our counsellor/support worker may contact your GP to alert them to a matter of concern or perceived (non-emergency) risk to you. This would normally be done in discussion with you and with your agreement, but in certain circumstances where it was not possible to contact you or the risk was deemed to be high, we may contact them without your agreement.

GP Practice Name*

GP Practice Address*

GP Practice Town*

GP Practice Postcode*

GP Practice Phone number*

Southend

About you

Contact details

Your GP

Support