Project Self-Referral Form — Stepping Stones North Wales

N.B. All data is held is the strictest of confidence and in accordance with Data Protection legislation. Details of our privacy statement are available on request.

About you: *

First Name

Last Name

Preferred name *

Your preferred pronouns

Are you 18 years old or under?

Yes

You email address *

Is it safe to email you?

Yes

Your phone number

(###)

###

####

Is it safe to call you on this number?

Yes

Your address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is it safe to write to you at this address?

Yes

What is your preferred method of contact? *

Phone call

Text message

Letter

Your date of birth *

YYYY

Your GP's name (if known):

Name of your GP's practice / surgery:

Your GP's address line 1

Your GP's address line 2

Your GP's postcode

Your GP's phone number

Are you accessing any other services? If yes, please give details below:

Do you have any criminal convictions? *

Yes

If you have selected yes, above, please provide any details of convictions here:

Service preferences:

Do you have any preference as to the gender of your counsellor?

Female

Male

No preference

Do you prefer to have a Welsh speaking counsellor?

Yes

No preference

How would you prefer to access counselling?

In person

Remotely online

Remotely phone

No preference

We work really hard to meet your service preferences as quickly as possible however, please be aware that very specific requirements may result in a slightly longer waiting time for our service.

Additional information:

Your gender:

Is your gender the same as the sex assigned at birth?

Yes

Prefer not to say

How would you describe your sexual or romantic identity?

If you have selected "other" above please describe your sexual or romantic identity here:

How would you describe your ethnicity?

What is your relationship status?

First language

English

Welsh

Other

Do you consider yourself to have a disability or health condition?

Yes

Prefer not to say

If you have selected 'yes' to having a disability or health condition, above, please provide details here:

Employment status:

Employed

Retired

Student

Volunteer

Unemployed

Thank you for completing this form. The information that you have provided will be reviewed and a member of our team will reply to you within three days to discuss organising your initial assssment.

If you have any concerns or questions you can call us on 01978 352 717.

Tŷ Aurora, 59 King Street, Wrexham. LL11 1HR | 01978 352 717 | [email protected]

Charity registration No. 1207418

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