Refer Myself - No Limits Trading

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info@nolimitstrading.org.uk

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"*" indicates required fields

I confirm that I am happy for you to hold my information*

Yes

We cannot accept a referral without you giving us your consent for us to hold your information for a limited period of time. Please check the box below to proceed

I understand and wish to proceed with you holding my information

Name*

Your email address*

Your phone number*

When we contact you about this referral, can we identify ourselves as No Limits?*

Yes

Please tell us anything else we need to know about getting in touch:

Your date of birth*

DD slash MM slash YYYY

Your postcode and/or town/city*

Your gender*

Your ethnicity*

Please let us know what you would like help with:*

Mental health/emotional wellbeing

Relationships or family life

General health, sexual health

Drugs and alcohol

LGBTQ+

Housing, money, employment

Support as a young carer

Membership of a support group

Support as a care leaver

Crime and offending

Other (please specify at the end of this form)

Please indicate your preferred method of counselling (you can choose as many as you want to) and we will try to accommodate you*

In person (35 The Avenue, Southampton, SO17 1XN)

by Zoom

by Phone

Please indicate your preferred days and times of counselling (please choose as many as you can) and we will try to accommodate you:

Days:

Monday

Tuesday

Wednesday

Thursday

Friday

Times:

AM (between 9am and 12:50pm)

PM (between 1 pm and 3:50pm)

Eve (between 4pm and 6:50pm)

Sessions are for 50 minutes, starting on the hour.
Please note that the last available session on a Friday starts at 4pm.

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info@nolimitstrading.org.uk

No Limits Trading, 35 The Avenue, Southampton SO17 1XN

Phone: 023-8022-4224
Email: info@nolimitstrading.org.uk

Registered Company number: 11167244

No Limits Trading are GDPR Compliant. Read our privacy statement here

0 2 3 8 0 2 2 4 2 2 4

info@nolimitstrading.org.uk

No Limits Trading, 35 The Avenue, Southampton SO17 1XN

Phone: 023-8022-4224 Email: info@nolimitstrading.org.uk

Registered Company number: 11167244

No Limits Trading are GDPR Compliant. Read our privacy statement here

Phone: 023-8022-4224
Email: info@nolimitstrading.org.uk