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Complex Care Counselling
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Self Referral
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The Form?
General
How did you find us?
Internet Search
Social Media
NHS Referral
Recommendation
MS-UK
Other Organisation – Please tell us who
Other Organisation – Please tell us who
How would you like to be contacted?
Email
Text
Phone
Other
Other
Sessions?
What is the referral for?
NHS Application
Self-Pay
Self-Pay to Start & NHS Application
Other
Other
Preference?
Video Sessions
Telephone
Other
Other
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
Other
Other
Address & Contact
Your Name?
PostCode?
Date of Birth
Phone Number
Email
Gender
Male
Female
Other
Gender
GP Details
Surgery Name
Postcode
Dr Name (if Known)
Home?
Relationship?
Single
Divorced
Live-In-Partner
Married
Children?
Yes
No
Have you got a carer?
Yes – Full-Time
Yes – Part-Time
No
Do they live with you?
Live-at-Home
Adult (my full-time carer)
Now Adults (left home)
Employment?
Employed?
Yes
No
Status
Full-Time
Part-Time
Are You Medically or Physically Able to Work?
Yes
No
Other
Are You Medically or Physically Able to Work?
Are You Retired?
Yes
No
Are You A Carer?
Yes
No
Are you a student?
Yes
No
Select Therapy
Your Counselling Topic?
*
Autism
Brittle Bones
BSL Therapy
Hearing Loss
Carer
Cerebral Palsy
Chronic Pain
Cochlear
Down's Syndrome
CODA
Dystrophy
Dwarfism
Dyslexia
Epilepsy
Head Injury
Limb Loss
Lumber Spondylosis
Multiple Sclerosis
Mutism
Parkinson's
Road Traffic Accident
Relationships
Skeletal Dysplasia
Spina Bifida
Spinal Cord Injury
Sight Loss
Tinnitus
Vestibular
Other
What?
If you are human, leave this field blank.
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