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Counselling Request Form

Name *
Name
dd/mm/yyyy
1st line of address
2nd line of address
Do you live in Sheffield? *
We are only able to offer Counselling to people who are resident in Sheffield at the time of their counselling. If you do not live in Sheffield, or will not be living in Sheffield for the foreseeable future, do not continue with this form and look for your nearest local support service.
Landline and/or Mobile
Is it ok to send post to your address? *
Is it ok to email you? *
Please select Yes or No
Is it ok to call you and leave a message? *
Consent given *
I consent to my data being used, as above.