Counselling Referral

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* 1. Please complete the following

Name

Address

Address 2

City/Town

ZIP/Postal Code

Email Address

Phone Number

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* 2. What is your preferred contact method to discuss your referral?

Email

Phone Call

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* 3. Have you had previous experiences with counselling?

No

Yes

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* 4. If yes please provide some details,

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* 5. Which form of counselling would you be happy with?

Video Call

Telephone Call

In Person

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* 6. Please write your name to confirm that you have read the counselling agreement and Data Protection statement on our website - https://www.doncasteralcoholservices.co.uk/counselling