Lamplight API response

First name

Last name

Address 1

Address 2

Address 3

Address 4

Address 5

Postcode

Email address

Mobile phone

Phone number

We need your permission to contact you to arrange your appointments. Please select all boxes of the following methods of contact that we can use to arrange your appointment. We will only use this to contact you while you are an active client. We won’t share these details with anyone else unless you have consented to this or we are required to by law.

By post

By email

By mobile

By text message

Other information

Confirm email address

Preferred contact method

Date of Birth

Number of children

Number of dependant children

Gender

Gender (other)

Sexuality

Sexuality (other)

Marital status

Occupation

Are you a smoker

Religion

Religion (other)

Are you currently a member of a church or religious group?

Name of church or group

Ethnic origin

Health

Do you consider yourself disabled?

If yes, please specify how your day to day activities are limited due to your disability or a health issue?

Do you need disabled access?

GP Details

Name of Doctor

Surgery name and address

Any current treatment / medication?

Are you currently seeing a Psychiatrist or mental health practitioner?

If 'yes' to the above what Hospital?

Hospital name (other)

Please state the name of your psychiatrist/mental health practitioner

Counselling

What type of counselling are you looking for?

Who referred or recommended or how did you find out about the MHCS?

Preference of counsellor

Would you be able to attend an initial assessment between Monday-Friday, 9am-3pm?

Please enter any details around you availability for counselling sessions

Counselling method preference

Face to face

Online

Telephone

Payment

Have you paid the admin fee?

Payment type

Date admin fee paid

Have you consulted anyone else about this problem?

If 'yes' whom

Are you still seeing them?

Please note that all applications require a £20 administration fee to be processed. To ensure your payment is matched correctly to your application, please make the payment using the following reference format:

[Your First Name] F1 (For example: Sarah F1)

When completing your online application form, you must indicate:

• Whether you have paid the admin fee

• The method of payment used

• The date the payment was made

Acct Name: The Manna House Trust | Sort Code: 08-90-73 | Acct Number: 50136872

Please be aware that applications without the admin fee may experience delays in being processed.

Refer to our services

Other information

Health

GP Details

Counselling

Payment