DisabilityPlus Self-Referral DisabilityPlus Self-Referral General How did you find us? SelectInternet SearchSocial MediaRecommendationMS-UKScopeAmputation FoundationOther Organisation – Please tell us who How did you find us? How would you like to be contacted? SelectEmail OnlyText OnlyText & EmailTelephoneOther How would you like to be contacted? Sessions? What is the referral for? SelectNHS ApplicationSelf-Pay to Start & NHS ApplicationSelf-Pay (immediate start)Other What is the referral for? Preference? SelectVideo SessionsTelephoneOther Preference? Counsellor Preference? SelectEitherMaleFemaleOther Counsellor Preference? Session fees? NHS Assessment Session = Free Introduction session (self-paid) = £50 3 sessions (self-paid) = £180 Pay-as-you-go (self-paid) = £70 Address & Contact Your Name? PostCode? Date of Birth 00/00/0000 Phone Number Email Gender MaleFemaleOther Gender GP Details Surgery Name Postcode Email Address (if known) Dr Name (if Known) Select Therapy Your Counselling Topic? * Autism Ataxia Brittle Bones Brain Injury BSL Cerebral Palsy Ehlers-Danlos Syndrome Endometriosis Epilepsy Downs Syndrome Hearing Loss Muscular Dystrophy Limb Loss Motor Neurone Disease Lumber Spondylosis Multiple Sclerosis Parkinson’s Rare Genetic Disorders Road Traffic Accident Skeletal Dysplasia Spina Bifida Spinal Cord Injury Sight Loss Tinnitus Vestibular Disorders Other Any, Secondary Conditions? Secondary Conditions None 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? Submit