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DisabilityPlus Self-Referral
Complex Care Counselling
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DisabilityPlus Self-Referral
DisabilityPlus Self-Referral
DisabilityPlus Self-Referral
What is the referral for?
Select
NHS Application
Self-Pay to Start & NHS Application
Self-Pay (immediate start)
Other
What is the referral for?
Preference?
Select
Video Sessions
Telephone
Other
Preference?
Counsellor Preference?
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Either
Male
Female
Other
Counsellor Preference?
How did you find us?
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Internet Search
Social Media
Recommendation
MS-UK
Scope
Amputation Foundation
Other Organisation – Please tell us who
How did you find us?
Address & Contact
Your Name?
*
Date of Birth
*
PostCode?
Email
*
Phone Number
Your Gender
Select
Male
Female
Other
Your Gender
GP Details
Surgery Name
*
Postcode
*
Dr Name (if Known)
Email Address (if known)
Select Therapy
Your Counselling Topic?
*
Select
Autism
Brittle Bones
BSL
Ehlers-Danlos Syndrome
Endometriosis
Cerebral Palsy
Downs Syndrome
Hearing Loss
Muscular Dystrophy
Limb Loss
Lumber Spondylosis
Multiple Sclerosis
Rare Genetic Disorders
Road Traffic Accident
Skeletal Dysplasia
Spina Bifida
Spinal Cord Injury
Sight Loss
Other
Secondary Conditions
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Asthma
Cancer
Chronic Fatigue Syndrome
Chronic Pain
Digestive Conditions
Diabetes
Epilepsy
Fibromyalgia
Heart Disease
Lung Conditions
Medically Unexplained
HIV
Musculoskeletal Disorders
Stroke
Sexual Dysfuntion
Other
Summary
Brief Summary?
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