Counselling
Registration Form
Please complete and return, with £5 registration fee (Cheques payable to Reach Merseyside)
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: _____________________________
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: ..............................