Couples Counselling Application Form

Personal Details

Title

Date of Birth (DD/MM/YYYY)

First Name

Last Name

Flat/House No. & Street Name

Town/City

Postcode

Mobile Phone

Home Phone

What is your preferred method of contact?

Can we leave a message on this number?

Relationship Details

Current Partnership Status

Please give details:

Does your partner consent to us contacting them to arrange Counselling as a Couple?

Partner's Details

Title

Date of Birth (DD/MM/YYYY)

First Name

Last Name

Do you share the same address?

Flat/House No. & Street Name

Town/City

Postcode

Mobile Phone

Home Phone

What is their preferred method of contact?

Can we leave a message on this number?

Cannot Proceed

Unfortunately, we cannot offer you Couples Counselling if your partner does not agree to the process. If you would like to arrange counselling for yourself, please click on this link which will take you to our Adult Counselling Registration Form

Data Protection Statement

Your personal information will be processed and kept secure in accordance with Mindspace Limited Privacy Policy(Statement and the full policy are available on our website) and in line with GDPR (2018) regulations. This includes processing your data for registration and your anonymised collective data for reporting and funding purposes. We will not pass your information to third parties without your permission. However, if we are concerned about your safety or the safety of others, and where required by law, we will give your details to appropriate third parties.

Do you consent to us keeping your details for the purposes outlined above?

Date of Agreement

Cannot Proceed

As you do not agree to us processing your details in line with GDPR regulations, we are unable to proceed with your application.

Contact Information