Online Counselling Registration Form

Please answer all the questions marked with an asterisk*. If you do not want us to know the answers to the other questions then leave them blank. All the information you give will be treated with the strictest of confidence. We will not, except in exceptional circumstances (see terms and conditions), contact any other party without first chatting with you about it.

If you have any questions about this form please e-mail: sam@visyon.org.uk

Have you read and understood
E-motion's terms and conditions*
User ID* 
Age*  
Sex:  

E-mail*

Please retype your E-mail address

Address

(please state a town/village name)
Telephone No.
When would be a good time
to meet you online?
Do you have access to
any one-to-one chat software
(e.g. MSN Messenger or ICQ)?
If yes, which would you
prefer to meet on?
Is there anything else
you would like to tell us/ask?

Thank you for taking the time to fill this form in. One of our counsellors will e-mail you in the next few days with some possible times and dates for a first meeting.