Contact info


 

We would prefer to contact you by email. Please supply us with an email address in the box below if you consent to this

 
 

Male FemaleOther

 
 

Telephone No (preferred number)


 

Can we leave a voicemail?

YesNo

 

Can we send you a text message?

YesNo

 
 

Can we leave a voicemail?

YesNo

 

What Towns/geographical areas are you able to get to?

Please tick area of preference

(It may be possible to arrange counselling elsewhere in NY where travel and access are difficult for you?)

York

Harrogate

Northallerton

Scarborough

Selby

Other

Do you consider yourself to have any special needs or disabilities?

If yes, please could you give brief details if possible?

YesNo

 

If you have a strong prefence to see a male or female counsellor this can be arranged

Strong preference to see a male counsellor
(Available at Northallerton and Scarborough)

Yes

 

Strong preference to see a female counsellor
(Available at York and Harrogate)

Yes

 

If you have strong preference to see a male or female counsellor but are unable to get to the areas listed above, please could you provide further echo details

If Possible, could you briefly state what your counselling issue is:

 

Thank you for taking the time to complete the online referral form. Once submitted you should receive a reply within 5 working days. For any queries, please telephone the YorSexualHealth Counselling Service booking line on: 01904 725444