Reach Logo   Counselling Registration Form

     Please complete and return, with 5  registration fee (Cheques payable to Reach Merseyside)

    The Appointments Manager, 85a Allerton Road,  Liverpool L18 2DA
      

I wish to be seen at:
Liverpool 
          New Brighton            West Kirby  
Chester             Manchester 

(Liverpool has stairs. Please let us know if this is a problem as other options may be available)

 

Name: (Mr/Mrs/Miss/Ms)_______________________________________________________________

Address:____________________________________________________________________________

____________________________________________ Post Code: _____________________________

e-mail: ____________________________ @ _______________________________________________
(This is only needed if you regularly check your e-mails, so we can use your e-mail address to contact you for appointments
Please can you mark e-mails from Reach as 'safe' so they do not get sent to the 'junk items' or 'spam' folder.)

Tel No: (day)______________________   Answerphone message to be left:     Yes        No  
Mob: __________________________      Answerphone message to be left:     Yes  
     No  
Age: ____________     Marital Status: _____________      Number of Children: _____ (under 18 yrs)

 

I became aware of Reach through:

  Friend / Relative / Neighbour              Reach Literature        Internet

  Passing By          Yellow Pages      Other Directory          Are you a previous client?

  Church                GP                       Other___________________________________________

 

I would be available for an appointment: (late afternoon appointments may be difficult to allocate)

  Morning       Early Afternoon       Mid Afternoon       Late Afternoon  (4pm onwards)

 

Please state any regular days that are NOT convenient for you: _______________________________________

Further information : Please give us your main reasons for wanting to see a counsellor.

This will help us in allocating the most appropriate counsellor available. A sentence or two is sufficient. This information is confidential.

 

 

 

 

In order to help trainee counsellors gain experience, we try to arrange for them to observe experienced
counsellors. If necessary, would you be open to this? (If applicable, you will be asked again at the time.)

   yes      no

Have you remembered to include your reg. fee?       yes 

Please indicate level of donation per session  ______                 Date: _____________________
NOTE: Please ensure you read the Donation Guidelines.     Click Here for Donation Guidelines

 

.                                                                   Please continue overleaf if necessary

For Office Use

 

Appointment Date: ................................................................    Client Notified: .........................................

 

Counsellors: .........................................................................    Couns Notified:  .............................................

                    

Date Returned: ..............................

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