Road Traffic Questionnaire Road Traffic Questionnaire Address & Contact Your Name? * PostCode? * Date of birth? * You would like? Pay-Privately Pay-Privately to Start & NHS Application NHS Application Employer Support Legal Referral OtherOther NHS Application NHS Funding Application’s are based on your exceptional circumstances. NHS Applications can take up to 12 weeks to get a decision. Pay Privately & NHS Application Paying privately allows you to start counselling quickly. When this form is completed, we will arrange your counselling. Fees Introduction Session £50 Pay-as-you-go £70 Saver3 (3 sessions) £180 NHS Application’s rate of success depends on your location. The standard timescales are eight weeks from when your GP sends our application to the funding panel. Pay Privately Paying privately allows you to start counselling quickly. When this form is completed, we will arrange your counselling. Fees Introduction Session £50 Pay-as-you-go £70 Saver3 (3 sessions) £180 Doctor Details Surgery Name Postcode Doctors email address Only used for NHS funding application Dr Name (if Known) Home? Relationship? Single Divorced Live-In-Partner Married Any, children at home? Yes No Children you care for Employment? Employed? Yes No Status Full-Time Part-Time Are You Medically or Physically Able to Work? Yes No OtherOther Are You Retired? Yes No Are you a student? Yes No Aspirations from counselling? Multi-select Facilitating behaviour change Enhancing coping skills facilitating your potential Development of self-worth Improving relationships Reduce anger Reduce negative feeling and thoughts Explore broad set of issues Reduce or remove addictions Establish and maintain relationships Remove or reduce negative cycles OtherOther Next