Talk Matters Counselling Services

Tel: 01383 626 064
Email: info@talkmatters.org

Online Request

If you wish to be added to our waiting list for an appointment to see one of our counsellors you can either contact us be calling the number above or by completing the form below.

Once your form has been processed we will send you confirmation of receipt by email.

Appointments will be offered by telephone. If you are not available at the time of the call a message will be left unless you have indicated otherwise. As you will appreciate we do have a waiting list and can therefore only give you 24 hours to respond to a message after which time the appointment will be offered to the next person on the list.

We will keep you on our list until we have successfully offered you an appointment or recieved your request to be removed.

You can get information on our current waiting times by contacting our office on 01383 626064. Evening appointments are always in more demand than daytime appointments so please consider this when indicating your available times.

Please answer all the questions.

Title:

Name:

Address:

Town/City:

Postcode:

Contact No:
(no spaces)

Mobile No:
(no spaces)

Email:

Other:

If for confidential reasons you do not wish us to contact you by letter.(please check box)
If for confidential reasons do not wish us to leave a telephone message. (please check box)
If for confidential reasons you do not wish us to contact you by email. (please check box)

Do you have a disability? Yes No If yes please specify:
Are you over the age of 18? Yes No

Please select your availability in the table below

	9:30am - 12pm	12pm - 5pm	5pm - 7:30pm
Monday
Tuesday
Wednesday
Thursday
Friday

Are you available on the same day and time each week? Yes No

If no please specify your reasons i.e Shift Worker:

How did you hear about us?

If you would rather post the form to us please click here to download form
and send the completed form to: Talk Matters, Ground Floor, New Dickson House, Dickson Street, Dunfermline, Fife KY12 7SL

If you are a health professional please click here to download form
and send the completed form to: Administrator, Talk Matters, Ground Floor, New Dickson House, Dickson Street, Dunfermline, Fife KY12 7SL

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Registered Scottish Charity: Talk Matters, Ground Floor, New Dickson House, Dickson Street, Dunfermline, Fife KY12 7SL Reg. No SCO 26976
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