Refer Yourself

Use this form to arrange counselling for yourself.

First name *

Where do you live? *

Please be aware, our counselling services are only available in Bradford.

What is your postcode? *

Remember, our counselling services are only available in Leeds and Bradford. You must enter a valid LS or BD postcode to be eligible.

Could you travel to the other if the need arose?

If you are a Leeds or Bradford resident, we might ask you to travel to the other city depending on counsellor availability.

How will you be getting there? * Telephone number *

Can we leave a message if we don't get you in person? * 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? * What are the main issue/s you would like to resolve during your time with a counsellor? *

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.

Are you able to communicate easily in English? * How old are you? *

How do you describe your gender? * If you selected other, please specify

Do you identify as a Trans person? How would you describe your sexuality? * If you selected other, please specify

What is your ethnic background? * Do you have a disability? * 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

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? Have you been diagnosed with a mental health condition (e.g. depression, eating disorder, psychosis, personality disorder etc.)? If you answered yes, please give details

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.)

I have read and understood the Yorkshire MESMAC privacy statement and agree to the use of my data in line with this policy *

Yes

We are committed to ensuring our counselling service is meeting the needs of the people who use it. Would you be happy for MESMAC to contact you when your counselling has finished (or when you end your counselling) for your feedback?

Yes No

You will receive an automatic message telling you that we have received your request for counselling.

If our service is not appropriate for you, we will try and let you know within two weeks of receiving your request – with some signposting options if available and relevant.

If our service is appropriate for you, we will attempt to match you with a counsellor within two weeks of receiving your request. You will then negotiate your first session with the counsellor.

Please note that these are guidelines, Yorkshire MESMAC counselling service has a restricted budget which is supplemented by donations to our charity from the public. At times of high demand and unplanned absence the indicative times may be exceeded. At these times we would aim to update the website.

Yorkshire MESMAC privacy statement

Click here to read

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Yorkshire MESMAC privacy statement