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PLEASE COMPLETE THE FORM BELOW AND THEN PRESS "SUBMIT"

Please note:-

> The counselling service operates on Tuesdays, Wednesdays, and Thursdays ONLY

> It is a fee based service - we are unable to offer free counselling. You will be offered an initial assessment appointment to discuss your counselling needs. Please note that the initial appointment is offered during the hours of 11:00 and 16:00 ONLY

By completing this form you agree that any personal information you share with Richmond Borough Mind will be kept secure and used in line with the General Data Protection Regulation 2018 (GDPR).

Click here for full details of GDPR: RBMind Privacy Policy

Identity

Forename

Surname

Please provide the name of your Next of Kin and related contact details e.g. Phone and e-mail. This can also be your GP Surgery.

Address

Address 1

Address 2

Town

Post Code

Please confirm if you are currently living within the London Borough of Richmond upon Thames (LBRUT)

Contact

Telephone

Mobile

Demographic

DateOfBirth

Ethnicity

Gender Identity

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

Sexual Orientation

Religion

Other Information

Employment. How would you describe your current situation?

Please tell us anything else that you think could be relevant for RBMind to know

Service Specific: Counselling & Psychotherapy

RBMind operates a sliding scale of fees. These charges are for each 50 minute session. Please indicate which charge applies to you.

Have you experienced discrimination due to a protected characteristic that you identify with. Please tick all that apply.

Please provide details for why you are seeking therapy

Health Information

GP Surgery Name

Do you consider yourself to have any of the following health conditions or disabilities

If you have been diagnosed with a Mental health condition, please describe your condition.

Have you been prescribed psychiatric medication, and if so, which ones?

If applicable, please provide the Name and Address of your Psychiatrist

Counselling & Psychotherapy