Lamplight API response

First name

Last name

Address 1

Address 2

Address 3

Address 4

Address 5

Postcode

Email address

Mobile phone

Phone number

To allow us to contact you regarding this referral and manage any future counselling service needs (such as appointments, changes to appointment, invoicing, terms and conditions), please consent to your preferred modes of communication below.

By post

By email

By mobile

By text message

Other information

GP Practice

Registered Doctor

Current medication

Any previous or current mental health diagnosis?

Consent to contact GP if we have any concerns about your wellbeing

Date of birth

Emergency contact name

Emergency contact's relationship to you

Emergency contact's contact number

Gender

Sexuality

Ethnicity

Religion

Marital status

Details of previous involvement with GP/ psychiatric team/psychologist

Employment status

In receipt of benefits?

If in receipt of benefits, which ones?

Applying for a bursary to fund counselling?

Total household income (inc. benefits) in GBP

Financial bracket

Any further details about financial circumstances

What are you hoping to gain from counselling?

Type of counselling

Are there any days/times in which you cannot receive counselling sessions?

Referrer details

Referrer name

Referrer email

Referrer phone number

Referrer position

Referrer organisation

Where did you hear about our service?

If 'Other' - details

Referral to PSS Counselling Service

Other information

Referrer details