Contact Form NameThis field is for validation purposes and should be left unchanged.If you feel it would be too difficult to talk on the telephone but would like to be added to the waiting list for counselling, please fill out this form containing the standard questions we would ask anyone who wants counselling.When we have received your answers, someone in the office may call to confirm certain details to ensure we are able to support you in the best way. There are quite a few so we suggest that you take it slowly and gently as some are tough. Please know that all the information that you provide will be treated in strictest confidence and in accordance with our privacy policy - Relevant details can be found on our website. Please let us know if you do not consent to your data to being stored.Full Name(Required) PrefixDrMissMrMrsMsProf.Rev. Prefix First Last Best contact number(Required)Email Address(Required)Home Address(Required) Street Address City County / State / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Date of Birth(Required) GP details(Required)We do not automatically contact our clients' GPsGenderMaleFemaleNon-binaryPrefer not to sayEthnic BackgroundAsian IndianAsian PakistaniAsian BritishAsian OtherBlack CaribbeanBlack AfricanBlack BritishBlack OtherMixed – Black Caribbean/WhiteMixed - Black African/WhiteMixed – Asian/WhiteMixed BritishMixed OtherWhite BritishWhite IrishWhite OtherOther – ChineseOther – Chinese/BritishAny OtherPrefer not to sayHow did you hear about Bereft?(Required)Have you ever attended counselling before?(Required) Yes No When and for how long?Was it helpful to you? Yes No Are you currently seeing a therapist?(Required) Yes No Please tell us about your bereavement/sWho has died?(Required)When was this?(Required)What was the cause of death?(Required)How old were they?(Required)Have you experienced any other bereavements(Required) Yes No Who has died?When was this?How old were they?What was the cause of death?Have you experienced any other bereavements Yes No Who has died?When was this?How old were they?What was the cause of death?Have you experienced any other bereavements Yes No Who has died?When was this?How old were they?What was the cause of death?Have you experienced any other bereavements Yes No Who has died?When was this?How old were they?What was the cause of death?Have you experienced any other bereavements Yes No Who has died?When was this?How old were they?What was the cause of death?Are you now, or have you ever been, a carer for another adult?(Required) Yes, currently Yes, in the past No On a scale of 1-10 (where 1=very poor and 10=very well), how would you say you are functioning on a day-to-day basis in relation to the following? Sleeping(Required)Please enter a number from 0 to 10.Eating(Required)Please enter a number from 0 to 10.Work LifePlease enter a number from 0 to 10.Study lifePlease enter a number from 0 to 10.Home/family life(Required)Please enter a number from 0 to 10.Social life(Required)Please enter a number from 0 to 10.Does your GP or any other health professional know what is going on for you at the moment?(Required) Yes No Are you talking to anyone else about this (employer/family/friends)?(Required)Do you have any chronic illnesses, mobility problems or mental health issues that we should be aware of?(Required) Yes No If yes, please provide details.Are you currently taking any form of medication to support your mental health?(Required) Yes No If yes, please provide details.Have you had or are having any suicidal thoughts, or have you made any plans?(Required) Yes No If yes, please give as much information as you feel you can.Have you been able to share this with anyone?(Required)If you decided to engage in bereavement counselling with us, we ask you to consider when would you be free to attend each week. We have bereavement counsellors who work mornings, some work in the afternoons, and others in the evenings. The more flexibility clients are able to offer, the more quickly we are able to allocate a bereavement counsellor to them. Please select all that apply.(Required) Monday 9:00-11:50am Monday 12:00-5:50pm Monday 6:00-8:50pm Tuesday 9:00-11:50am Tuesday 12:00-5:50pm Tuesday 6:00-8:50pm Wednesday 9:00-11:50am Wednesday 12:00-5:50pm Wednesday 6:00-8:50pm Thursday 9:00-11:50am Thursday 12:00-5:50pm Thursday 6:00-8:50pm Friday 9:00-11:50am Friday 12:00-5:50pm Friday 6:00-8:50pm Our bereavement counselling sessions are delivered either in-person or remotely. Please tell us your preferred medium. Please select all that apply.Session Preference(Required) In-person Remote We ask everyone that attends counselling with Bereft to consider making a donation for each session in order to keep the service going. We suggest anything from £25-£40 per session. However, we do understand that this may not be possible for everyone and ask you to consider what might be manageable for you at this time.Donation amount(Required) I can donate £25 or more I can donate £5 - £25 I can donate up to £5 Please provide details of someone that we could contact in the event of an emergency during a session, or if we became very concerned about your well-being. These details will be stored securely and will not be used for any other purpose.Name of emergency contact(Required)Relationship (family member, friend, etc)(Required)Number of emergency contact(Required)If there is any other information you feel we should have, please share it here:Thank you for sharing this information. One of the team will contact you to confirm receipt of your form and answer any queries. Please indicate below suitable times for us to try to contact you.Office contact times preference(Required) Mondays: Between 10.00 pm and 1.00 pm Tuesdays: Between 12.00 pm and 5.00 pm Wednesdays: Between 12.00 pm and 5.00 pm Thursdays: Between 10.00 am and 11.30 am Fridays: Between 10.00 am and 2.00 pm Prefer email contact: Δ
