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  q   New Brighton  q   Chester  q   Manchester  q   Southport  q

(Liverpool, New Brighton and Southport all have 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 we can use your e-mail address to contact you for appointments)

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

I became aware of Reach through:

q  Friend / Relative / Neighbour            q  Reach Literature      q  Internet

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

q  Church (Name of Church / Leader )____________________________________________________

q  GP / Medical       q  Other__________________________________________________________

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

q  Morning     q  Early Afternoon     q  Mid Afternoon     q  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. 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.)

q   yes    q  no

Have you remembered to include your reg. fee?     q  yes 

Please indicate level of donation per session  £______                 Date: _____________________
If you need to be reminded about this at any point please ask

.                                                                                                          Please continue overleaf if necessary

For Office Use

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

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

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