121 Counselling

We are delighted to extend our one to one counselling support service as part of our charitable aims and objectives to support the LGBT+ community in Northumberland and beyond. Northumberland Pride have contracted specialist providers to deliver this service alongside us. 

You can either refer someone you know or self refer using the form below. We aim to respond to you within 72 hours from submission and arrange an appointment within 7-10 working days if we are able to support your request. 

This is not a crisis service, please contact your local crisis team or call 111 or 999 in the event of an emergency.

Client Personal Information

Enter the client's forename.
Enter the clients preferred name.
Enter the client's surname.
Enter a contact number for appointments.
Enter an email address for appointments.
For example; he/him, she/her, they/them
If client is under 16, please enter a parent/guardian's name and contact number.

Address Information

Enter a street and house number.
Optionally enter a town

Preferences

If they are, please provide some detail regarding this.
Please select any special requirements you might need (Select all applicable).
Please select a service.
What type of appointment would suit you best?

Issues

Please give a brief summary of why support is required (including any relevant medical/family history and when you are available).
Please tick if you have previously seen one of our counsellors?
If you have used the service before, please give us some details on this.
Select one or more of the issues you are experiencing.

General Practitioner Details

New General Practitioner Form

If our GP was on the list above, please enter N/A in all fields that do not apply to you.

Family Members

Please let us know if you want a family member or friend to attend appointments, and, enter their details below.
Enter their forename.
Enter their surname.
Enter their contact number.
Enter a street and house number.
Optionally enter a town.
Select a county
Enter postcode.

Consent

Communication Permission

Leave unchecked and we will not contact you via this method

 

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