Contact Form 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) First Last Home Address(Required) Street Address City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Best contact number(Required) Email Address(Required) Date of Birth(Required) MM slash DD slash YYYY GP details(Required) We do not automatically contact our clients' GPsHow did you hear about Bereft?(Required) Have you ever attended counselling before?(Required) Yes No When and for how long?(Required) Was it helpful to you?(Required) Yes No Are you currently seeing a therapist?(Required) Yes No Please tell us about your bereavement/sWho has died?(Required) How old were they?(Required) When was this?(Required) Please tell us briefly what happened(Required) Please tell us about any other bereavements you have experienced.(Required) Are you now, or have you ever been, a carer for another adult?(Required) Yes, Currently Yes, in the past No How would you say you were functioning right now, in relation to eating, sleeping, work, family/social life?(Required) 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, friends, family)?(Required) Yes No Are you on any form of medication such as anti-depressants, anti-anxiety, sleeping medication etc?(Required) Yes No Have you had or are having any suicidal thoughts, or have you made any plans?(Required) Yes No Have you been able to share this with anyone?(Required) Yes No If you decided to engage in bereavement counselling with us, 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.Is any time/day ok?(Required) yes no When is the best day/time for you?Monday morning afternoon evening Tuesday morning afternoon evening Wednesday morning afternoon evening Thursday morning afternoon evening Friday morning afternoon evening Saturday morning afternoon Our bereavement counselling sessions are currently being delivered remotely (online or telephone). We will be offering face-to-face sessions again (date to be confirmed) but please tell which is your preferred medium?Session Preference(Required) Online Phone Face-to-face Flexible If there is any other information you feel we should have, please share it here: We hope to hear from you when you are ready. Once we have received your form, one of the team may call you to establish how we can best support you. Please indicate below suitable times for us to try to contact you. If you prefer not to be called, please tick the relevant box and we will email you instead.Session 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 Fridays: Between 10.00 am and 2.00 pm Saturdays: Between 10.00 am and 12.00 pm Prefer email contact: Δ
