Child Enquiries Form

Who you are
Young Person (over the age of 16)Young Person (under the age of 16)Parent / Guardian

Note if you are under 16 we do require parental / guardian consent

Parent / Guardian's first Name

Parent / Guardian's name last Name

Parent / Guardian's email

Parent / Guardian's telephone number

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First Name

Last Name

Gender
MaleFemaleNon-binaryTransgenderOther

Your email

Your telephone number

Your DOB
enter your date of birth

Reason for seeking counselling?

Your availability (Day)
MondayTuesdayWednesdayThursdayFriday

Your availability (Time of Day)
AMPMEvening

Prefered Contact Method
EmailPhone CallText

Any additional information that may be useful to know?

Would you like a free 20 minute phone call
NoYes

if yes to the above please provide a few dates / times suitable for you.

Have you had a formal diagnosis or are you seeing a Psychiatrist?

Your preferred counsellor
No preferenceAlyChelsea

How did you hear about us?

GDPR: Please confirm you agree to us securely storing your data
Agree