Request an Appointment 
Please fill in this form for referral to our counselling service in Ashton-Under-Lyne and Oldham. Filling out the form will put you on our waiting list and we will contact you as soon as a counsellor becomes available. We are open on a Tuesday evening weekly between 5 and 9.

If you would like to find out more please don't hesitate to contact us using the number on our website or use the request a call on our form.
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Name *
Phone Number *
Email Address
Request a call back (for more information or to speak to a member of staff. We will aim to contact you within 3 working days) We may contact you on a blocked number.
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Gender
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Date Of Birth
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Address
Which Site would you like to access? 
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Preferred time (click all that apply, other time is for phone clients only)
Presenting issue

If you are unavailable to take our call...

Can we leave an answer voice mail or text message?

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Can we leave a message with the person answering the phone? If so who?
Any other requirements/medical issues you would like us to know?
Have you experienced counselling before?
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How did you hear about us?
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