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Refer Yourself

Refer yourself to MESMAC's counselling service using our online form. Tell us a little about you and our team will be in touch.

Please note the counselling service at MESMAC cannot respond to crisis emotional / mental health situations.

If you feel you are in need of crisis emotional / mental health support - contact your GP or telephone the Samaritans national support line on 116 123 - their telephone line is open 24/7.

First Name

Where do you live?

Please be aware that our counselling services our only available in Bradford, Hull, Leeds and South Yorkshire

What is your postcode?

Could you travel to a different site 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 travelling to sessions?

Phone number

Can we leave a message if we can't get through to you?

Are there any times you prefer us not to ring?

Are there any other ways that we can contact you (eg email)

In case we are unable to contact you by phone

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 your counsellor's gender?

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?

Do you identify as a trans person?

Yes

How would you describe your sexuality?

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 ever been diagnosed with a mental health condition (eg depression, eating disorder, psychosis, personality discord, etc)?

If you answered yes, please give details

Is there anything else you can tell us about your physical or mental health? (eg any addictions, self-harm, long-term health condition, etc)

Privacy Statement

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

We are committed to ensuring our counselling service is meeting the need of 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?

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, 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.

MESMAC privacy statement

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Read our privacy statement