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.

Please note: Questions marked with a '*' are required.

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)

None of the above (not eligible)

*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)

Phone Number *

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 *

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.
Information about your health and medication.
Feedback from you about our service, as outlined in our Client Evaluation Form.

We use this information to provide a safe and high-quality service to you.

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.

We will never share your session notes, these are confidential.

By submitting this form, you agree to The Harbour storing and sharing your data 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 (opens in a new window).

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