Olive Branch

Date of Birth (Please note we can only see ages 18 plus)

How do you define your sexuality? Please leave blank to decline.

Have you been to Olive Branch Counselling before? (Please note, if you have had counselling with us before, you must wait a minimum of 6 months BEFORE you can register again

NoYes

If yes, can you remember roughly when it was?

Which counsellor did you see at that time?

Do you have any known contacts with Olive Branch staff or volunteers that might impact your counselling with us?

Do you consider yourself to have a disability?

Do any contact restrictions apply when contacting you (please elaborate if so)?

Which GP surgery are you registered with?

You can look up surgery names here: https://www.nhs.uk/service-search/find-a-gp

Are you seeing any of the below medical health professionals at the moment?

Please tick below to confirm how Olive Branch Counselling can contact you. Please note that we send all our appointment allocations via email, so it will difficult to allocate you to a therapist if you opt out.

PhoneEmailText

Please select as many or as few as you wish.

Are you a shift worker?

YesNo

In order for us to provide counselling, we require you to agree to our terms & conditions and privacy policy. Please tick this box to confirm your agreement to both. Please note, we will be unable to process your referral if this is declined.

Do we have your permission hold special category data (data which you may give during assessment that is personal - see privacy policy for more information)? Please note, we will be unable to process your referral if this is declined.

How would you prefer your counselling to be delivered?

How did you hear about us?

We can only accept clients over the age of 18. Please tick this box to confirm you are over the age of 18.

We can only accept an application from a prospective client themselves. Can you confirm that you are the client enquiring about counselling for yourself.

Olive Branch Counselling Self-Referral

Olive Branch Counselling
Self-Referral