Beacon Counselling

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Beacon Counselling

NOTE: THIS SITE IS NOW AT

www.beacon-counselling.org.uk

(Registered Charity No. 1109545)

Adult Counselling Appointments

Please fill out the details below to request an appointment with Beacon Counselling. Once you have completed the form, please click the submit button so we can view your details and add you to our waiting list. Alternatively you can contact via telephone during offices hours on 0161 440 0055.

Title:
Other (please specify):

First Name:
Surname:
DOB (day month year):

Daytime Telephone Contact numbers: (between 9.30-12 noon and 4.30-7pm)

Work:
Ext:
Home:
Mobile:
Email address:
Address:
Postcode:

How did you hear about us?

Website
GP
Health Care Worker
Friends/relatives
Other (Please specify)

Do you have transport?

Yes
No

Can we send information about our services to your home address via post?

Yes
No
If you would like information to be sent to a different address, please state:

Can we also send information via email?

Yes
No
If you would like information to be sent to a different address, please state:

When are you available?

Daytime only
Evening only
Anytime