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First name *

Last name *

Email *

What kind of therapy are you looking for? *

We only work with adults. For further help please visit: https://www.mind.org.uk/for-young-people/how-to-get-help-and-support/useful-contacts/

Do you live in the UK? *

Yes

We can only offer support in the UK.

What city do you live in? *

What's your date of birth? *

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We only work with adults. For further help please visit: https://www.mind.org.uk/for-young-people/how-to-get-help-and-support/useful-contacts/

What is your relationship with alcohol? *

I don't drink

It does feature in my social life, but I got it covered

I think I may have a problem with drink

I am addicted to alcohol

Short term counselling is not suitable for working with addiction. For further help please visit: https://www.mind.org.uk/information-support/types-of-mental-health-problems/recreational-drugs-alcohol-and-addiction/drug-and-alcohol-addiction-useful-contacts/

What is your relationship with drugs? *

I don't take drugs

They do feature in my social life, but I got it covered

I think I may have a problem with drugs

I am addicted to drugs

Are you currently employed? *

Yes

How would you describe your finance situation at the moment *

Good

Average

Poor

Do you have any mental health diagnoses? *

Yes

Please give details

Are you currently taking medication? *

Yes

Please give details

Where did you find out about UPRAWR counselling service?

Where did you find out (Other)

Is there anything else we need to know about you or what you're hoping to get out of therapy? *

Yes

Please give details

By submitting this message I agree to the Uprawr Foundations T&C's*

I must provide a contact number so the UPRAWR Mental Health Foundation can conduct the necessary triage calls. *

I must provide a contact number so the UPRAWR Mental Health Foundation can conduct the necessary triage calls.*

I must reply within 48 hours of the UPRAWR Mental Health Foundation contacting me to organise a session/ keep my sessions. *

I must reply within 48 hours of the UPRAWR Mental Health Foundation contacting me to organise a session/ keep my sessions.*

If I miss 2 counselling sessions, my scheduled sessions will be given to somebody else. (If you miss a session, we may still have to pay for it, please do not take space from people who need help if you can't attend you sessions.) *

The UPRAWR Mental Health Foundation operates during standard office hours Monday to Friday, and messages will only be responded to within those working hours. *

The UPRAWR Mental Health Foundation operates during standard office hours Monday to Friday, and messages will only be responded to within those working hours.*

Although this counselling is being offered for free, it is an expensive service for UMHF to provide and therefore must be utilised and treated respectfully. *

Although this counselling is being offered for free, it is an expensive service for UMHF to provide and therefore must be utilised and treated respectfully.*

I understand that failure to comply with these terms and conditions will result in me being moved to the back of the waiting list or discharged from the service. *

I understand that failure to comply with these terms and conditions will result in me being moved to the back of the waiting list or discharged from the service.*

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There's something in your form submission that means we can't offer you suitable support. Please check your answers.

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