in West Essex

Private Counselling

Please provide us with as much of the following information as you feel able to. We will use this information to allocate you to an appropriate therapist so the more you can tell us the better.

Please ensure that we have full contact details as without them we will not be able to contact you to arrange a suitable appointment:

Please indicate if you are affected by any of the following:


Confidentiality & Data Protection:
Mind in West Essex is committed to maintaining client confidentiality. All information about you is held securely and not shared with anyone outside our organisation without your permission, or unless exceptional circumstances occur. If you wish to see the records we hold about you this can be arranged by request to the Chief Executive Officer of Mind in West Essex. If we believe there is a risk of harm to you or someone else we will inform the appropriate person (such as your GP or other health professional), but we would always endeavour to discuss this with you in advance.
Your data is held electronically on a secure data base and will be retained with any associated paperwork for a period of 7 years.
Declaration
I declare that the information provided by me is accurate to the best of my knowledge.
If I choose to go ahead and receive counselling through this service, I hereby authorise Mind in West Essex to store personal information related to me and the service I receive..
If you are happy to accept the above terms and conditions please tick the following box and click on the button marked submit.

Thank you for enquiring about the Mind in West Essex Counselling service. We aim to make contact with you within 1 working day.



*We will not be contacting your GP as a matter of routine, we ask this question only so that if at any point we have serious concerns about your safety or the safety of others we can take appropriate action.

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