Counselling Self Referral — Every pregnancy has a story. Whatever your story, you have Choices.

By completing this form, you are consenting to Choices storing your data. This means that we will store it securely and control who has access to it. At Choices, we recognise that the information you provide may be sensitive and we will respect your confidentiality. We will not share any information where we are not legally required to do so. Your data will be stored securely only for as long as the data is needed for in accordance with the Article 89(1) of the Data Protection Act 2018.

If you have any questions, please email:
info@choicescharity.org

Self-Referral Form

Counselling Service Required *

Please select which counselling service you would like support from

What is your first name? *

What is your last name? *

What is your contact number? *

What is your email address? *

What are you hoping to gain from counselling support?

Do any of the following impact on you?

Do any of the following impact upon why you would benefit from this support? (select all that apply)

Unplanned pregnancy

Mental health challenges

Physical health challenges

Single Parent

Low Income

Domestic Abuse

Currently Homeless

Currently Unemployed

Relationship Breakdown

NRPF

Receiving Benefits

What is your ethnicity? *

What is your age? *

Which borough do you live in? *

What is your religion? *

Do you have a disability? *

How did you hear about Choices?

Thank you for getting in touch, we monitor our inbox regularly and will get back to you as quickly as we can.

The Choices team

Stay in the loop

First Name

Last Name

Email Address

Thank you for signing up to the Choices newsletter!

Choices

390 Caledonian Road,
London, N1 1DN

info@choicescharity.org

Choices offers counselling for unplanned pregnancy, during pregnancy, following pregnancy loss and for post abortion concerns. We also offer practical and therapeutic help with parenting including our parenting course.

Choices is an independent and confidential counselling service, as we are a non-medical agency we cannot refer directly for termination. Therefore, you can be sure of impartial support. We will discuss all options with you and can signpost you to other organisations and agencies whatever decision you reach. We are an organisational member of the British Association for Counselling & Psychotherapy (BACP). Registered charity no. 1124209

Read our Policies: Safeguarding Adults at Risk Safeguarding Children Privacy