Counselling Enquiry 01732 605046 Tonbridge Counselling Service, First Floor, Gilbert House, River Walk, Tonbridge, TN9 1DT info@tonbridgecounsellingservice.co.uk Please enable JavaScript in your browser to complete this form.Full name *Date of Birth *Email *Single Line TextNumbersSingle Line TextGP Name, and Surgery:Reason for seeking counselling at this time (more time will be given to this during the initial assessment) *Is there any current risk that you might harm yourself?Do you have accessibility requirements?Have you had therapy before?YesNoAvailability for sessions (Days)MondayTuesdayWednesdayThursdayFridaySaturday morningPreferred time of dayMorningAfternoonEveningPreferred mode of sessionIn personOnlineTelephonePreferred method for initial contactCall (Landline)Call (Mobile)TextLetterEmailIf we are unable to get hold of you are you happy for us to leave a message on your mobile or landline?YesNoGDPR Agreement *I agree for TCS to use my contact details for the purpose outlined below *Consent and confidentiality: To protect your confidentiality, the information that you share with us is held on a fully encrypted database which complies with the TCS GDPR and Privacy Policy and is only accessible by your individual therapist and the Manager of TCS. Your record has to be kept for 5 years after which it will be deleted. Please be aware that if you choose to pay via BACS/cheque/iZettle your name will appear on the TCS bank statement. Please be aware that your name will be visible to our administrator Jill Gibbs who has no access to information regarding your counselling sessions and is committed to maintaining your confidentiality. By completing this form you are consenting that information can be shared about you a) within TCS to provide you with a service b) with third parties if any immediate risk of harm to self or others are identified c) if we are required to by a court. Please indicate your agreement for TCS to use your contact details for the purposes of delivering you a responsive counselling service. Your information will never be used for marketing purposes.GDPR Agreement (copy) *I have read the TCS Privacy Statement *Submit