Enquiry Wizard

Complete the following form to submit a request for counselling at North East Counselling

Client

Please select from drop-down list
Enter forename
Enter preferred name if applicable
Enter surname
Enter contact number
Enter email address
Enter house number and street
Enter town/city
Select country from drop-down list
Select county from drop-down list
Enter full postcode including the space separator (e.g BT3 9DT or SW1A 1AA)
Enter date of birth
Select gender from drop-down list
Select pronoun from drop-down list
If under 16 enter name and contact number
Enter name of school
Select the referral source from the drop-down list, eg Friend, GP, School, Self Referral etc


Please select all issues that apply from the drop-down list
Please provide brief details of why support is required.
Search and select your gp or use the '+' icon below to add your gp if not found
Please provide details of days/time you are available

Family Members

Family Member Information

Tick if this family member may attend appointments.
Enter family members forename.
Enter family members surname.
Enter family members email address.
Enter family members date of birth.
Select the family members relationship.
Select the family members gender.
Enter family members contact number.
Please enter a contact number

Address Information

Tick if you would like to copy the address from the primary client.
Enter a street and house number.
Please enter a street
Optionally enter a town.
Please enter a town
Select a country
Please select a country
Select a county
Please select a county
Enter full postcode including the space separator (e.g BT3 9DT or SW1A 1AA)
Please enter a valid postcode
  • No family members added.

Consents

How we use client information

We may use client information to carry out our obligations arising from any contracts entered into by the client and us. We promise to keep your details safe and secure. We will not share your information with third parties for marketing purposes. We may contact you to let you know about other services, events or for evaluation purposes.

The circumstances when details can be shared include:

  • When a counsellor has good grounds for believing that a person may cause serious harm to themselves or others.
  • When we are instructed by a court to disclose information.
  • When a person discloses criminal activity, or knowledge of criminal activity, this includes statutory obligations.
  • When it is necessary to uphold child protection laws.

Your responsibility

We would ask that you keep us informed (by email, telephone, or in writing) of any changes in your personal data so that we may have our records up to date at all times. If you wish to withdraw your consent please contact us (by email, telephone, or in writing). You have the ‘right to be forgotten’, which means you can request the deletion or removal of personal data where there is no compelling reason for its continued processing.


GP/3rd Party Consents

I consent that you can share details with my GP and other 3ʳᵈ parties who are involved in the contract entered into by you and us

Our data is sent anonymously to the NHS so that they can track mental health in our area. The data set is used to inform service improvements and monitor service performance,
clinical interventions, patient experience and treatment outcomes. Are you happy for your data to be sent to the NHS?

Communication Consents

Tick your preferred methods of consent from the list below. Please TICK ALL that apply (a minimum of one must be selected)

I consent that I'd like to hear from you via email

I consent that I'd like to receive phone calls from you and you can leave voice messages

I consent that I'd like to receive SMS texts from you

I consent that I'd like to receive letters from you