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Christian Counselling

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Registration Form

New Registration Form

Preferred Venue

NB Liverpool and Sheffield have stairs. Please let us know if this is a problem as other options may be available.

Name

Prefix First Last

Address

Street Address Address Line 2 City Post Code

Email

Enter Email Confirm Email

Mobile or daytime number

Age

Marital Status

Number of children U18

Occupation

I became aware of Reach through

Friend / Relative / Neighbour

Reach Literature

Website / Google

Church

Passing By

GP

Are you a previous client?

Other

Please specify

I would be available for an appointment

Morning

Early Afternoon

Mid-Afternoon

Late Afternoon (4pm onwards)

NB Late afternoon appointments may be difficult to allocate

Inconvenient Days

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.

Consent

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

I agree

Please indicate level of donation per session

If you are a taxpayer please tick the Gift Aid box:

I want Reach to treat as Gift Aid all donations made since 6th April 2001 and all future donations until I notify you otherwise. I have paid enough UK income or capital gains tax to cover all my charitable donations; other taxes such as Council Tax and VAT do not qualify. I will advise Reach of any change in my circumstances.

I am a taxpayer

Registration Fee(Required)

I will submit my form and pay my £5 registration fee now using the Paypal option on the next page. The Paypal link will allow you to use your own credit/debit card - no Paypal account is required.

I will submit my form and pay the £5 registration fee by other means.

Name

This field is for validation purposes and should be left unchanged.

Δ

Once you click the submit button your form will be submitted. You will then be automatically taken to our ‘To Donate’ page where you will see the options to pay your £5 registration fee. Please note that your registration is not complete until you have paid this.

Reachfor a better life

Contact us

Reach, 85a Allerton Road, Liverpool, L18 2DA
0151 737 2121
Email: [email protected]

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Venues

Liverpool ‐ Manchester ‐ Chester ‐ West Kirby ‐ Sheffield – Wrexham – Staffordshire & North Shropshire – Remote

Reach Counselling Limited is a Registered Charity No. 701330
Company limited by Guarantee No. 225358
© Reach Counselling Limited 2025