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Title *

—Please choose an option—MissMrsMsMrDrOther

First Name *

Last Name *

Date of Birth *

—Please choose an option—01020304050607080910111213141516171819202122232425262728293031—Please choose an option—JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember—Please choose an option—201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900

Gender *

—Please choose an option—FemaleMale

Marital Status *

—Please choose an option—SingleMarriedDivorcedSeparatedWidowedCohabitingPrefer not to say

Employment Status *

—Please choose an option—EmployedSelf-employedHomemakerUnemployedRetiredStudentInspirited Minds TeamPrefer not to say

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Organisation * (Please provide your NHS organisation)

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Religion *

—Please choose an option—MuslimChristianJewishHinduSikhBuddhistOther religionNo religionPrefer not to say

Ethnicity *

—Please choose an option—White - BritishWhite - IrishAny other White backgroundAsian/Asian British - IndianAsian/Asian British - PakistaniAsian/Asian British - BangladeshiAsian/Asian British - ChineseAny other Asian backgroundBlack/Black British - CaribbeanBlack/Black British - AfricanAny other Black backgroundMixed - White and Black CaribbeanMixed - White and Black AfricanMixed - White and AsianAny other mixed backgroundOther Ethnic Groups - ArabAny other ethnic groupPrefer not to say

Address *

City *

Postcode *

Country * (Currently we only provide counselling to those within the UK)

—Please choose an option—United Kingdom

Please state whom you are seeking help for *

—Please choose an option—MyselfFamilyFriendNeighbourOther

Preferred Counsellor Gender *

—Please choose an option—FemaleMaleDo not mind

Preferred Counsellor Language *

—Please choose an option—EnglishArabicBengaliDutchFrenchGujaratiHausaPunjabiSomaliSpanishTamilTurkishUrdu

Have you been referred to us by someone *

—Please choose an option—NoYes

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Who were you referred by *

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Please select which areas you would like support for *

AbortionAbuseAddiction(s)ADHDAdoptionAnger managementAnxietyAttachment disorderAutismBereavementBipolar disorder/Manic depressionBullyingCancerCareerCarer supportChild related issuesChronic fatigue syndrome/MEDementiaDepressionDisabilitiesDissociationDomestic violenceDrug abuseEating disordersHearing voicesInfertilityLearning difficultiesLonelinessLow moodLow self-confidenceLow self-esteemMiscarriageObsessive compulsive disorder (OCD)Paranoid personality disorderPassive aggressive behaviourPersonality disordersPost-traumatic stress disorder (PTSD)Pregnancy and birthPsychosisRelationship issuesSchizophreniaSelf-harmSex addictionSex problemsSexualitySpiritualityStressSuicidal thoughtsTraumaWork-related stressOther

Please provide more details about what you are seeking help for *
[be as detailed as you can; i.e. what form(s) of illness you suffer from, what sort of help you are seeking, what you current situation is, if you have previously or are currently receiving any support or medication]

Telephone *

Email Address * [group nhs inline](Please use your NHS email address)[/group]

Confirm Email Address *

I am aware that my details may be shared with the team and third party advisors. I am aware that, although Inspirited Minds promise to ensure that every case is dealt with in a professional and confidential manner, in special circumstances, (eg: if it is felt that the person who contacted may be in danger or may be under-age), there may be a breach of confidentiality *

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