Self Referral Free Funding Self-Referral All The Form? General How did you find us? Internet Search Social Media NHS Referral Recommendation MS-UK Other Organisation – Please tell us whoOther Organisation – Please tell us who How would you like to be contacted? Email Text Phone OtherOther Sessions? What is the referral for? NHS Application Self-Pay Self-Pay to Start & NHS Application OtherOther Preference? Video Sessions Telephone OtherOther Aspirations? 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 Address & Contact Your Name? PostCode? Date of Birth Phone Number Email Gender MaleFemaleOther Gender GP Details Surgery Name Postcode Dr Name (if Known) Home? Relationship? SingleDivorcedLive-In-PartnerMarried Children? YesNo Have you got a carer? Yes – Full-TimeYes – Part-TimeNo Do they live with you? Live-at-HomeAdult (my full-time carer)Now Adults (left home) Employment? Employed? YesNo Status Full-TimePart-Time Are You Medically or Physically Able to Work? YesNoOther Are You Medically or Physically Able to Work? Are You Retired? YesNo Are You A Carer? YesNo Are you a student? YesNo Select Therapy Your Counselling Topic? * AutismBrittle BonesBSL TherapyHearing LossCarerCerebral PalsyChronic PainCochlearDown's SyndromeCODADystrophyDwarfismDyslexiaEpilepsyHead InjuryLimb LossLumber SpondylosisMultiple SclerosisMutismParkinson'sRoad Traffic AccidentRelationshipsSkeletal DysplasiaSpina BifidaSpinal Cord InjurySight LossTinnitusVestibularOther What? If you are human, leave this field blank. Next