First name *
Where do you live? *
Remember, our counselling services are only available in Leeds, Bradford and Wakefield.
Leeds Bradford Wakefield What is your postcode? *
This is so that we know we are providing a full service across the whole of the West Yorkshire region covered by Yorkshire MESMAC.
Could you travel to the other two if the need arose?
If you are a Leeds, Bradford or Wakefield resident, we might ask you to travel to one of the other two cities depending on counsellor availability.
Yes No How will you be getting there? *
Walking Public transport Car 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? *
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 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 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 *