Secure Counselling Request Form

Personal Information

Select your preferred title.
Enter your title if not available in dropdown list.
Enter your forename.
Enter your surname.
Select how you identify.
If you self describe please specify.
Select your date of birth.
Enter your address.
Enter your address.
Select the county you live in if available.
Select the country you live in if available.
Enter your postcode.

Contact Information

Enter your home number.
Enter your mobile number.
Enter your email address.

Our phone will display as a private number.

General Practitioner

Select a GP if available.
Check if your GP isn't available in the above list.


Select the preferred gender of your counsellor if applicable.
Select your preferred location for counselling.
One one or more times you are available.
If the above does not apply enter here.
Please select how you found out about Nexus NI.
If other please enter an other value.