Lamplight API response

First name

Last name

Address 1

Address 2

Address 3

Address 4

Postcode

Email address

Mobile phone

Phone number

We will normally contact you by email. If you wish to be contacted in a different way please select your preference below.

By post

By email

By mobile

By text message

Other information

Date of birth

Gender

Ethnic identity

Doctor Surgery

Please specify

Number to be used for text reminders of sessions

Details of referral

Has the person being referred had any experience of Counselling in the past?

If yes please give details

Has the person being referred been diagnosed with any mental health conditions?

Details of any mental health diagnosis

Is GP Aware of this referral

Is the person being referred feeling suicidal?

Does the person being referred have a diagnosed eating disorder?

Does the person being referred have a history of self harm?

Are their any issues with drugs or alcohol consumption?

If you have answered yes to any of the questions above please provide details here

Is the person being referred Autistic?

Does the person being referred have ADHD

Name of Referrer if not self

Email address of Referrer

Mobile Number of Referrer

Relationship of client to referrer

Name of emergency contact

Relationship to client

Phone Number of emergency contact