Perth College Student Counselling Request

Your name*

First Last

Date of birth*

Data protection legislation requires that we obtain your explicit consent to keep records. Records include: your contact details, information such as practitioner notes, and assessment information. Please use this form to confirm consent. We keep all records in accordance with current General Data Protection Regulations. See https://www.rowan-consultancy.co.uk/privacy-policy for our policy on how we keep your data.

Data consent*

I agree that Rowan can hold my personal and sensitive data according to Rowan's privacy policy.

Please download and read this leaflet about the terms and conditions for counselling at Rowan Consultancy.

Terms and conditions*

I have read and agree to the terms and conditions outlined in Information for Perth College Students leaflet, including the 24 hour cancellation policy.

Your email*

Enter Email Confirm Email

Your phone number*

How do you prefer us to contact you?*

Tick all that apply:

No preference
Phone
Text
Email

Your address*

Street Address Address Line 2 City ZIP / Postal Code Country

Can you tell us the name of your GP Practice?*

Yes
No

GP Practice name*

GP Practice address

Please give us any other information you can remember about your GP Practice address

What type of counselling would you prefer?*

Tick all that apply:

No preference
Face to face
Phone
Online

Your availability to see a counsellor?*

Tick all that apply:

Weekdays 9am - 5pm
Weekday evenings
Weekends

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Comments

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