Mind in West Essex Counselling Service
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Confidentiality & Data Protection
Mind in West Essex is committed to maintaining client confidentiality. All information about you is held securely and not shared with anyone outside our organisation without your permission, or unless exceptional circumstances occur. If you wish to see the records we hold about you this can be arranged by request to the Chief Executive Officer of Mind in West Essex. If we believe there is a risk of harm to you or someone else we will inform the appropriate person (such as your GP or other health professional), but we would always endeavour to discuss this with you in advance.
Your data is held electronically on a secure database and will be retained with any associated paperwork for a period of 7 years.
Declaration
I declare that the information provided by me is accurate to the best of my knowledge.
If I choose to go ahead and receive counselling through this service, I hereby authorise Mind in West Essex to store personal information related to me and the service I receive.
If you are happy to accept the above terms and conditions please tick the following box and continue with the form:*
I am happy to accept the above terms and conditions.
Would you like to sign up to the newsletter?
Yes
No
Which service(s) would you like to be referred to?*
Bereavement Counselling - £45 per session
Counselling - £45 per session
Couples Counselling (both people would need to register) - £60 per session
Life Management Skills £45 for initial consultation - £30 support sessions
Low Cost Counselling - £15 per session
Have you been experiencing suicidal feelings?*
Yes
No
Do you have a suicidal plan?*
Yes
No
Your Details
Date of Birth:*
Title:*
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Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name:*
Last Name:*
Gender:*
Male
Female
Not known
Not specified
Address Line 1:*
Address Line 2:
Town/City:*
County:
Postcode:*
Email:*
Home Number:
Mobile Number:*
Preferred method of contact (tick all that apply)
Text
Call
Email
Post
Is it OK to leave a message?*
Yes
No
Are you happy to receive text messages?*
Yes
No
GP Details
GP Name:
GP Practice:*
GP Phone Number:
Are you happy for us to inform your GP that you have undertaken therapy?*
Yes
No
Would you like to tell us what issues counselling will help you with?*
Is there anything else you would like to tell us at this stage?*
Please indicate if you are affected by any of the following
Addiction and dependency
Alcohol
Drugs
Self Harm
Suicidal Plan
Anger
When are you available for appointments?*
Preferred location (tick all that apply)*
Great Dunmow
Harlow
Saffron Walden
Preferred Session Type (tick all that apply)*
Face to face
Telephone
Video
How did you hear about this service?*
Are you aware that we are a fee-paying counselling service?
Yes
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