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Low Cost Counselling Service

Client Registration Form

Please complete this form if you would like to register for the Low Cost Counselling Service (LCCS).

Please note that all fields with a red * are compulsory fields and you will not be able to submit this form without completing them

*Please note that completing this form is not a guarantee of getting counselling.  This is a registration form which needs to be reviewed and assessed for suitability and availability*

Identity

Address

Contact

Medical contacts

Consent

Demographic

Additional Information

Referral Information

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 South East London Mind to store personal information related to me and the service I receive.

Consent to keep information about you

Here at South East London Mind, we are committed to protecting your personal information and making every effort to ensure that your personal information is processed in a fair, open and transparent manner.


The type of data that will be collected and used:

Personal information we collect includes details such as your name, date of birth, gender, email address, postal address, telephone number and credit/debit card details (if you are making a purchase or donation), as well as information you provide in any communications between us.

Special Category Personal Data:

Here at South East London Mind’s Low Cost Counselling Service the type of special category data we collect may include personal data revealing racial or ethnic origin, sexual orientation, and religious beliefs.

Why we want to use your data

·       To provide the services that you have requested.

·       To update you with important administrative messages about the services you have requested.

·       To keep a record of your relationship with us.

·       Where you volunteer with us, to administer the volunteering arrangement.

·       Where you are a client accessing our services, to ensure we provide you with the best services and to meet the needs of our funders’ monitoring procedures.

·       To contact you about our work and how you can support South East London Mind.

·       To invite you to participate in surveys or research.

If we don’t have this information, we are very limited in the services and support that we are able to provide.

***If you are happy to accept the above terms and conditions please submit this form.***