Lamplight API response

First name

Last name

Address 1

Address 2

Address 3

Postcode

Email address

Mobile phone

Phone number

By clicking "allow to contact by post, email, mobile or text" you consent to being contacted by WCC in regards to accessing our services. Clicking these boxes will not mean you are contacted in regards to marketing or campaigns.

By post

By email

By mobile

By text message

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Other information

Date of referral to WCC

Are you a Lambeth resident?

Personal Details

Preferred Pronoun

Date of birth

Gender

If other gender, please specify

Sexuality

If other sexuality, please specify

Country of origin

Ethnic origin

Language(s) spoken

Albanian

Amharic

Arabic

Bengali

Cantonese

English

Farsi

Farsi (Dari)

French

German

Hindi

Hungarian

Igbo

Italian

Japanese

Konkani

Korean

Kurdish

Mandarin

Marathi

Pashto

Polish

Portuguese

Punjabi

Romanian

Russian

Somali

Spanish

Sylheti

Tamil

Tigrinya

Turkish

Twi

Urdu

Vietnamese

Yoruba

Religion

Disability

Blind or Visual Impairment

Deaf or Hearing Impairment

Learning

Mental Health

Mobility

None

Other

Do you have any access needs that we should know about?

Level of English

Could the client receive counselling in English?

Specific times available

Housing status

Living situation

Employment status

Student

Freelance

Full time work

Part time work

Retired

Sick

Volunteer

Unemployed

No permission to work

Other

Immigration Status

If other immigration status, please specify

Specific client experience

Fled war

Victims of domestic abuse

Victim of sexual violence

Victim of a Violent Crime

Human trafficking

Modern slavery

Victim of torture

Persecuted due to sexual orientation

Persecuted due to religious beliefs

Political Persecution

Ethnic Persecution

Childhood sexual abuse

Being a parent

Being a carer

None

Year of arrival into UK

I confirm I have not been informed by authorities that I am due to be moved outside of London in the next year

I am aware that I am no longer living in London, Waterloo Community Counselling would no longer be the right service to support you

Present Network (including family, friends, professional involvement)

Experience of living in exile

History of traumatic experiences of actual, threatened or witnessed torture and/or ill-treatment

Prior contact with counselling/psychiatric services or with GP for emotional/psychiatric problems

Previous Use of Counselling / Psychotherapy

Psychiatric History

Risk of harm to self and/or others

Medication

Medical Diagnosis

Hospitalisation

Have you ever been diagnosed with or sought treatment for any of the following mental health conditions:

Depression

Anxiety

Bi-Polar Disorder

Any Personality Disorder

Post Traumatic Stress Disorder (PTSD)

Schizophrenia

Psychosis

Prefer not to say

Other

What is the name of your GP practice?

Do you consented for WCC to contact your GP as required?

Are you currently receiving counselling or psychotherapy elsewhere?

What is your preference for counselling?

In Person (face-to-face)

Telephone

Online

Friend, housemate or family member recieving concurrent support with WCC?

Name of friend / family member accessing WCC service

MECS Group Activities

Would you like to receive information about WCC's social groups?

WCC has a partnership with St Johns Waterloo (73 Waterloo Road, SE1 8TY). St Johns provides activities as part of its ‘Room for You’ – these activities are open to WCC referrals and the wider community

Please indicate if you would be interested in attending any of the following and we will support you in accessing these activities.

English Conversation Club (weekly Tuesday 10-11:45 & 4-6)

Chess Club (weekly Tuesday 4-6)

Art Club (weekly Tuesday 1:30-3:30)

Gardening Club (weekly Wednesday 10-3pm)

Creative Writing Workshops (every 1st Wednesday of the month 6:30-8)

Space for Storytelling (every 2nd Wednesday of the month 6:30-8:30)

Walking group (every Tuesday 10:30-12pm).

Culture Club (check website for more information)

Click to indicate you consent to being contacted by phone or email by our partners at St Johns so that you can join the activities

Would you like to be added to our Mailing List (includes marketing, fundraising news and updates) Click to opt in

Referrer Details (if being made by third party)

Referrer Name

Referrer Phone Number

Referrer Email Address

Referrer Organisation

Referrer Role / Connection to the Client

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Language Counselling for Refugees & Asylum-Seekers Referral Form

Other information

Personal Details

MECS Group Activities

WCC has a partnership with St Johns Waterloo (73 Waterloo Road, SE1 8TY). St Johns provides activities as part of its ‘Room for You’ – these activities are open to WCC referrals and the wider community

Referrer Details (if being made by third party)