How we can help

First Name (required)

Last Name (required)

Address Line 1 (required)

Address Line 2

City (required)

Postal Code (required)

GP name & Practice (required)

Date of Birth (required)

Ethnicity: (required)
—Please choose an option—WhiteWhite BritishWhite IrishWhite Gypsy or Irish TravellerWhite EuropeanOther WhiteMixed/Multiple ethnic groupsWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed/Multiple ethnic backgroundAsian/Asian BritishIndian / British IndianPakistani/Pakistani BritishBangladeshi/BritishChinese/BritishAny other Asian backgroundAfrican/Caribbean/Black BritishBlack BritishAfricanCaribbeanAny other Black/African/Caribbean backgroundArabAny other ethnic groupPrefer not to say

Preferred telephone number to contact you (required)

Your Email (required)

We are not in a position to offer counseling in a different language at the moment, but if in the future the opportunity does arise, would you prefer a different language?
—Please choose an option—yesno

if yes, what would be your preferred language?

Allow email to book and confirm appointments (required)
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Allow Email updates about news and events (required)
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Allow post (required)
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Allow contact by phone to book and confirm appointments (required)
—Please choose an option—YesNo

Allow contact on mobile phone to book and confirm appointments (required)
—Please choose an option—YesNo

Allow texts, including appointment reminders via Cliniko (required)
—Please choose an option—YesNo

Do you have any access requirements?

I give my consent to Quetzal to contact me and to store my contact information.