Initial Therapy Enquiry Form | The Harbour (CRM)

This form is to determine whether The Harbour is the right place for you to access counselling at this time. If you would like help completing this form, or would like any further information, please call us on 0117 925 9348.

The Harbour is not a crisis service. If you are in immediate crisis please telephone 0800 953 1919 where you may speak with a practitioner working on the NHS urgent mental health helpline for Avon and Wiltshire, or you may speak with The Samaritans on 116 123.

Reason for seeking counselling

The Harbour supports adults (18+) who have been affected by life threatening physical illness. If you are seeking therapy, live in Bristol or surrounding areas and have been affected in one or more of the following ways please tick the appropriate box(es) and complete this form. You will then receive an email from us with further information and next steps.

Please tick all that apply: *

I am facing death or dying

I am close to someone facing death or dying

I have been bereaved as the result of a physical illness (over 3 months and less than 2 years ago)

*From our experience over many years, we have found that the immediate aftermath of a bereavement may not be the best time to access our services, and so we would ask you to wait three months from the bereavement before making contact with us.

Please state the main condition or illness involved *

Condition/illness (self-describe) *

Your details

First Name *

Last Name *

Preferred name (optional)

Pronouns (optional)

We will usually send our referral form to you as a weblink to your email. If you need your referral form in a different format or require help to complete your referral form please tick one of the following: *

How would you prefer to be contacted? *

By email

By phone

Email *

Phone Number *

Street Address *

Street Address Line 2

City

Postal Code *

How we store and use your data

We collect the following information about you as part of our counselling service:

Contact details, including your address, phone number and email address.
Emergency contact details.
Your date of birth.
The name and address of your GP.
Equalities monitoring information.
Session notes.
Feedback from you about our service, as outlined in our Client Evaluation Form.

We use this information for the following:

To provide a safe service to you.
To evaluate and improve our service.
For marketing and fundraising activities.

We will share your information in the following circumstances:

When we feel there is a risk of serious harm to yourself or someone else. In this instance we will contact your GP and/or other statutory services or service providers to let them know our concerns. When possible, we will contact you first before we do this.
When we liaise with other services who may have had contact with you, for example when you are referred to us, or when we refer you to another service.
When we produce anonymised reports on the impact and outcomes of our service. These reports may be for external funders, or they may be for internal evaluations and service developments.

Please note that we reserve the right to contact your GP if we feel there is a threat of serious harm to yourself or others.

Please confirm whether you consent to our data use policy *

I consent to The Harbour collecting, storing and sharing my personal information as described above

You can update your contact preferences at any time by emailing us at info@the-harbour.org.uk, or calling us at 0117 925 9348. We take your privacy seriously. You can read our Privacy Policy page here.

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