First name *
What towns or geographical areas can you get to? *
Remember, our counselling services are only available in Leeds, Bradford and Wakefield.
Telephone number *
Can we leave a message if we don't get you in person? *
Yes No Are there any times you prefer us not to ring?
Are there any other ways that we can contact you? (e.g. email)
In case we are unable to contact you by telephone
Is the counselling for you as an individual or a couple? *
Individual Couple What are the main issue/s you would like to resolve during your time with a counsellor? *
How will you be getting there? *
Public transport/walking Car What days and times are most convenient for you? *
Do you have a strong preference for a male or female counsellor? *
Depending on counsellor availability in certain areas, we may not have a choice in this regard, but if we do we will always take your preference into consideration.
I would prefer to see a male counsellor I would prefer to see a female counsellor I am happy to see either Are you able to communicate easily in English? *
Yes No If not, what language is it best to talk in?
Could you please give the first half of your postcode and the number after this? (e.g. LS1 3) *
This is so that we know we are providing a full service across the whole of the West Yorkshire region covered by Yorkshire MESMAC.
How old are you? *
How do you describe your gender? *
Male Female Other If you selected other, please specify
Do you identify as a Trans* person?
Yes No How would you describe your sexuality? *
Gay man Lesbian/ Gay woman Bisexual Heterosexual/ Straight Other If you selected other, please specify
What is your ethnic background? *
White- White British White- White Irish White- Other White Mixed- White and Black Caribbean Mixed- White and Black African Mixed- White and Asian Mixed- Other Mixed Asian/ Asian British- Indian Asian/ Asian British- Pakistani Asian/ Asian British- Bangladeshi Asian/ Asian British- Other Asian Black/ Black British- Caribbean Black/ Black British- African Black/ Black British- Other Black Chinese Other Ethnic Group Do you have a disability? *
Yes No If yes, please select which one is your main disability
We will contact you for more information and if we need to make any adjustments
Mobility Learning disability Sight impaired Hearing impaired Other If you selected other, please specify
Have you ever had or are you currently having any psychiatric treatment or prescribed medication to help with psychological problems?
Yes No Have you been diagnosed with a mental health condition (e.g. depression, eating disorder, psychosis, personality disorder etc.)?
Yes No Is there anything else you can tell us about your physical or mental health (e.g. any addictions, self-harm, long-term health condition etc.)