Please fill in the form below
In order for us to best understand how to support you in our groups and workshops, it’s important that we gather some information about you, your estrangement and your wellbeing. This should take no more than 5-10 minutes to fill in. Please be aware we won’t be able to respond to your personal circumstances at this stage, but this form will allow you to access our groups and workshops, where you can find support with your situation.
Where did you hear about us?
Street and House no
Emergency Contact Phone
Who are you experiencing estrangement from?
Mother and Father
Mother, father and siblings
More than one child
Children and grandchildren
More than one sibling
Multiple family members
How long have you been experiencing estrangement?
6 Years +
Briefly tell us about your estrangement in your own words... (max 100 words)
Please describe your thoughts on reconciliation
I definitely want to reconcile
I might want to reconcile
I'm not sure if I want to reconcile
I don't want to reconcile
Are you currently seeing a counsellor, therapist or psychologist?
Yes, I am currently seeing a therapist
Not at the moment
I've never seen a counsellor or therapist
I'd prefer not to say
GP's name and address
Have you ever been diagnosed with any of the following?
Have you been prescribed medication in relation to this diagnosis?
Name of medication
Tell us about your wellbeing strategies. How do you look after yourself?
Talking to a counsellor/therapist
Spending time with friends
Tell us about your support network
I have strong connections with others
I have some connections with other people
I don't feel connected to other people
Please set up three goals you would like to achieve by attending our support group or workshop
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