Client contact form

Please take a moment to fill out the form.

Your full name

Date of birth

Home address

Mobile phone number

GP practice name and address

GP phone number

Emergency contact name *

Emergency contact phone number

I give consent for Zena Nicholas Counselling to collect, process, store and erase my personal data as set out in thePrivacy policy

** For our online sessions, it's preferable for me to have an emergency contact. While we conduct our sessions virtually, unforeseen situations can still arise where immediate assistance may be needed. Having your emergency contact information allows me to reach out to a trusted person in case of an emergency or crisis during our online sessions. If you have any questions or concerns about providing your emergency contact details for our online sessions, please let me know. Your comfort and well-being are important to me, and I'm here to address any queries you may have.

Thanks for submitting!