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Complex Care Counselling
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Self-Referral
DisabilityPlus Self-Referral
General
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?
How would you like to be contacted?
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Email Only
Text Only
Text & Email
Telephone
Other
How would you like to be contacted?
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Sessions?
What is the referral for?
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NHS Application
Self-Pay to Start & NHS Application
Self-Pay (immediate start)
Other
What is the referral for?
Preference?
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Video Sessions
Telephone
Other
Preference?
Counsellor Preference?
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Either
Male
Female
Other
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
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Address & Contact
Your Name?
PostCode?
Date of Birth
00/00/0000
Phone Number
Email
Gender
Male
Female
Other
Gender
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GP Details
Surgery Name
Postcode
Email Address (if known)
Dr Name (if Known)
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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
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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
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Summary
Brief Summary?
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