Dartmoor Centre

Please fill out the form below as accurately as possible

After you have submitted the information one of our management team will contact you to arrange to go over it in more detail.

About You

Your Name (required)

Your Address (required)

150 characters remaining

Your Email (required)

Your Phone Number

Preferred Initial Contact Method (required)
This is how we will contact you to arrange a short assessment call.
EmailPhone

Restrictions on contact
Are there any things we shouldn't do when contacting you (e.g. don't leave message on answerphone).

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Emergency Contact

Name (required)


Relationship to you (required)


Tel. No. (required)

Preferences

Your Availability
This is your availability week on week for your counselling appointment. Please only choose times that you are regularly available.

Counsellor Gender Preference (required)
MaleFemaleNo Preference

More About You

Date of Birth (required)
On a mobile device touch the year on the date picker to change it quickly.

Age (required)

Health Conditions and Medication (required)
Tell us here about any health conditions that you think might affect your counselling and any medications that you have been prescribed for your mental health.
(Please type 'none' if there are none)

600 characters remaining

Are you able to climb a flight of stairs?
YesNo

Your Dr. or Surgery Name (required)

Are you presently engaged with any other agencies?
Please list any other agencies that you have had contact with.

Do you have any links to DCCP? (required)
Is anyone you know already receiving a service from us or does anyone you know work for us?
YesNo

Who referred you to us?

Your Donation

How much can you afford to donate for each session? (required)
Only enter an amount that is affordable to you, this can always be renegotiated at a later date but be realistic about what you can afford.
£

Other Details

What do you want from counselling? (required)
What is your desired outcome from a series of counselling sessions?

600 characters remaining

Your Background? (required)
Give us as much background about the reason that you would like to engage with a counsellor as you can.

1200 characters remaining

Once you click send below, the information is sent to one of our managers who will get in touch with you soon to arrange a phone call where we can go through your answers and check that we have all of the relevant information.

Please check the box below to confirm that you understand this and give us permission to arrange a short call with you. (required)
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