Waiting List Notice: OPEN Counselling spaces* are now available! Fill out our online form to arrange your initial intake assessment. Flexible availability helps us book you in sooner. *Spaces subject to suitability and counsellor match

Online Application Form

Our counselling sessions are not free, please read our Making an Appointment page before completing this form to find out more..

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

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COUNSELLING ENQUIRY FORM

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Title & 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 *

Where did you find out about us?

~~ 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

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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

Online Application Form

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Off The Record Counselling Service , Willow Lane House , 9 Willow Lane , Norwich, NR2 1EU . Phone: 01603 626650 . Email: info@otr-norfolk.org.uk ©2026 Off The Record Counselling Services (Norfolk) Limited . Company Number : 3974890 . Registered Charity Number : 1088504

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