New Patient Registration

    I give consent for the personal information below to be used by Life In Action Limited for the purpose of helping the client find the right counsellor. It will be deleted/shredded after the details are confirmed and processed with the office and when/if you take up counselling with one of the team. This is inline with our data policy.
  • Please provide your details so we may contact you
  • What is your/child client’s address?
  • What is your contact phone number? (Enter at least one number) Please tick the box to confirm we can contact you on and leave messages from the Service on the above number(s)
  • Please let us know how you came to contact us. e.g a Dr referred you to us or you were passed our number from someone you know.
  • Please tell us if you are receiving some other support
  • Do you/the child client have any physical disabilities that make it difficult or impossible to climb stairs?
    Select the main option below that best describes your reason for seeking counselling:
  • let us know and we will try to match you where we can to the right therapist. This may depend on the issues you are facing. We will discuss this with you before any agreement is sought.
  • How much can you comfortably afford to pay on a regular weekly basis? We may have a waiting list for some counselling
  • What days can you/the child client attend at a regular time each week? For each day of the week please state the best day for you. If you have a set time you are looking for please indicate this in the section below.
  • Please let us know if you have a specific time you are looking for on a set day.
  • Please confirm all the following points:
  • Thank you for completing this form. Once submitted a member of the office staff will contact you within 1-2 working days to confirm your details with a view to arranging an appointment for you as soon as possible. In the meantime, please contact the office on 01476 575933 should you wish. Regards, Life In Action Counselling Team
  • This field is for validation purposes and should be left unchanged.