Thank you for taking time to fill in this form. Please answer as many questions as you can.

When you submit your form, you will be placed on our waiting list. Our Admin team will call you as soon as we have a gap that fits with what you have told us.

Thank you.

About you

☐ Yes
☐ No
☐ Female
☐ Male
☐ Non-binary
☐ Prefer not to say
☐ Employed
☐ Self-employed
☐ Unemployed
☐ School (add name below)
☐ College
☐ University
☐ Apprenticeship
☐ Prefer not to say
☐ Other
☐ Living alone
☐ With partner
☐ With parent(s)
☐ Caring for children
☐ Caring for relatives
☐ Prefer not to say
☐ Other
☐ Yes
☐ No

Your main concerns

☐ 0 Not at all
☐ 1
☐ 2
☐ 3
☐ 4
☐ 5
☐ 6 A huge amount
☐ 0 Not at all
☐ 1
☐ 2
☐ 3
☐ 4
☐ 5
☐ 6 A huge amount

Your Availability (under 18)

In general, the more availability you can offer, the quicker we will be able to offer you an appointment.

☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No

Equality, Diversity and Inclusion

This section is optional, but we would be extremely grateful if could complete it as our key funders need this information to be able to help us sustain our low-cost counselling service. Please complete as much of it as you are willing to. Your data will be treated as strictly confidential and only stored on our secure database in compliance with GDPR legislation. All data shared from the form will be anonymous.

☐ White English/Welsh/Scottish/Northern Irish/British
☐ White Irish
☐ Gypsy/Roma or Irish Traveller
☐ Other White background
☐ Mixed White and Black Caribbean
☐ Mixed White and Black African
☐ Mixed White and Asian
☐ Other Mixed background
☐ Indian
☐ Pakistani
☐ Bangladeshi
☐ Chinese
☐ Other Asian background
☐ Black Caribbean
☐ Black African
☐ Other Black background
☐ Arab
☐ Other ethnic background
☐ Prefer not to say
☐ Gay
☐ Lesbian
☐ Heterosexual
☐ Bi-sexual
☐ Prefer not to say
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Christian
☐ None
☐ Buddhist
☐ Sikh
☐ Muslim
☐ Hindu
☐ Prefer not to say

Inclusion (under 18)

☐ Yes
☐ No
☐ Yes
☐ No

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Please note, while our counsellors are working remotely, we will pass your full name, address and contact details onto your counsellor for use in the event of a medical emergency. Please be assured that these details will be stored securely by your Counsellor. If you would rather we did not do this, please email reception@wellspringcounselling.org.uk.