Off The Record Counselling Service Willow Lane House 9, Willow Lane Norwich NR2 1EU

Online Application Form

The information you provide on the counselling application form will be used to contact you regarding counselling and appointments as set out in our Privacy Policy.

Please read the information we have on Gift Aid before ticking the Gift Aid boxes on the form.

You can also read and download our information forms by clicking on the link here ~ Client Information Forms

~ Waiting List ~

CLOSED

Please DO NOT fill out the application form and send to us when the list is closed as it will not be put into our system.

Your form message has been successfully sent.

You have entered the following data:

COUNSELLING ENQUIRY FORM

Please correct your input in the following fields:

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Name: *

Date of Birth: *

Phone Number: *

E-mail address: *

House Name/Number: *

Post Code: *

Would you prefer a face to face session, remote session or either? *

Can we leave a text ,a voice message or either *

Do you have any problem climbing stairs or need disabled access / other special facilities *

~~ GIFT AID ~~ AT NO COST TO YOU ! For every £1 you pay of your session donation or any other donation to OTR, OTR receives 25p from the Government. So please tick these first 2 boxes if you pay tax on your income. It makes all the difference.

~~~~ GIFT AID DECLARATION ~~~~ I’m a UK Tax Payer & I’d like OTR to reclaim the tax on all qualifying donations I’ve made, and any future donations. I understand that if I pay less tax than claimed on my donations, I’ll pay the difference.

I am not a UK Tax Payer.

I do not want to Gift Aid my donations

For the Intake Assessment Appointment please state the days & times you are available. Enter either ~ Mornings (9am-1pm), Afternoons (1pm-6pm), Evenings (6pm-8pm), Anytime or if day specific. *

For the Weekly Counselling Sessions please enter either ~ Same, or if different to the Intake Assessment Appointment , the days & times you are available (as stated above) *

Please add any Information here that you feel will be helpful

Captcha (spam protection code): *

I hereby agree that my data entered in the contact form will be stored electronically, and will be processed and used for the purpose of establishing contact and my information being used in accordance with OTR’s Privacy Policy. I am aware that I can revoke my consent at any time.

Note: Fields marked with * are required

~ Waiting List ~

CLOSED

Unfortunately, all our spaces are now full so we have had to close our waiting list.

Please check this page regularly to see when it is open again.

Do not fill out the online application form when the list is closed as it will not be put on to our system.

Other low cost counselling providers you may like to try

Or The Counselling Directory website where you will find all other low cost & private counselling providers .

Our Recent Donors:

Off The Record appreciate the support they have had over the last year from individual fundraising efforts as well as charitable grants through National Lottery Community Fund, Norfolk Community Foundation and the Geoffrey Watling Charity, which have helped the organisation continue its valuable work and ensure that counselling remains accessible to all.

Trustees

Lucy Ashby

Paul Burnett

Molly Heron

Head of Service

India Kirby

Head of Administration

Lisa Burnett

Please contact via

admin@otr-norfolk.org.uk

Counsellors & Office Staff

Please contact via

info@otr-norfolk.org.uk

The Counselling Directory is a nationwide database of qualified counsellors and therapists which offers an advanced search tool that allows you to filter your search according to your needs and location. Or, if you’d rather receive support remotely, you can find a therapist offering online or telephone services.

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© 2017, Off The Record Counselling Service (Norfolk) Ltd
Off the Record Counselling Service Ltd is a registered charity and a company limited by guarantee.
Registered Charity No. 1088504
Incorporated under the Companies Act 1985, No. 3974890

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