Online Counselling Services Order Form


NAME?
	
AGE?
	
MALE/FEMALE?
	
MARITAL STATUS?
	
ANY CHILDREN?
	
IF SO, WHAT AGES?
	
DO YOU WORK?

IF SO, WHAT IS YOUR JOB?
	
HOW ARE YOU FEELING?
	
CAN YOU GIVE A BRIEF DESCRIPTION OF YOUR PROBLEM?
	

I enclose a cheque for the sum of 

£15.00	[  ]	1 reply by email counselling
 
£30.00	[  ]	3 replies by email counselling

£50.00	[  ]	10 replies by email counselling (popular)

Please make cheque payable to: Andrea Greenhalgh
Post to: OCS,  9 Coronation St, Great Harwood, Lancs, BB6 7SL

I have read and agree to the terms and conditions below [  ]	  


Signature……………………………………………………………………………………..

Terms & conditions 
1. You must be 18 years or older to use the services of Online Counselling Services. 
2. You must not be using the services of another Counsellor. 
3. If you wish to receive email replies on certain days, then please specify which days are better for you. 
4. All email correspondence will be kept strictly confidential. Only I have access to my computer, and on completion of our sessions all emails will be erased. 
5. All replies to emails will be within 48 hours, unless specific reply days have been requested. 
6. The only time that confidentiality will be broken is if I feel that your life, or the life of another human being is in imminent danger. Before another party is involved, you will be contacted, and involved in the decision.