Secure Counselling Request Form

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Web Referral Form

Nexus NI offer counselling to survivors of sexual abuse, rape and sexual assault. If you would like counselling please complete this form and we will contact you. We will keep your details confidential (please refer to our website for our policy on confidentiality)

Title

Forename (required)

Surname

Are you
MaleFemaleTransgender

Date of Birth

Address one

Address two

City

Postcode

Home Phone

Mobile* (required)

Email

Allow contact by phone/mobile:* (required)
yesno

OK to leave messages?* (required)
yesno

If we ring you back our number will display as private number.

OK to send text reminders for appointments?
yesno

Do you consider that you have any physical disability that could affect counselling?
yesno

Details

Counsellor Preference:
malefemalenone

What is your preferred Location for Counselling?

What times are you available to attend counselling?

Have you attended NEXUS before?
yesno

Who told you about Nexus?

WebThe RowanGPHealth professionalPoliceFamily/FriendsContact NILifelineSocial workerWomen’s AidNSPCC

Other (please specify)