Request Counselling

Your Name *

First Name

Last Name

Your Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client Relation and Awareness *

I am the client.

The client (someone else) is aware of this request.

The client (someone else) is not aware of this request.

Client Name

If different

First Name

Last Name

Client Address

If different

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client Status

Is UK Resident

How is the client affected by cancer? *

Has been diagnosed

Is a family member of someone diagnosed

Is a carer of someone diagnosed

Name Of Consultant/ Specialist Nurse (If known)

First Name

Last Name

Child Information

Complete if client is 17 or under

I am the parent / guardian

Client has an assigned social worker

Fees and Subsidies

Please select the ONE that applies most.

This is cancer related and I am requesting a free of charge service.

This is cancer related and I am able to pay for this service to enable others less fortunate to benefit from subsidised sessions.

This is a non-cancer related issue and it is understood that payment per session is is required.

I am requesting this service for someone else and I will be responsible for any charges incurred .

This appointment is being booked under an existing SLA or partnership agreement.

I understand and consent to the following:

-Information sharing necessary for the referral -The counselling coordinator will contact you and/or client directly -This is not a crisis service. There may be a waiting list. -Retention of information. -Contact is permitted in relation to charity services (information will not be shared with outside 3rd party)

I understand and consent