← Back Your details First Name * Last Name * Address Line 1 (Door Number) * Street Name * City * Post Code * Mobile Phone Number * Email * Date of Birth * Emergency contactPlease provide the details of someone we can contact in an emergency if we are unable to reach you. This information will be held securely and will not be shared with your counsellor. Emergency contact full name Relationship to Youe.g. partner, parent, friend Emergency contact phone number Your GPWe collect GP details in case we need to contact them in a safeguarding emergency. These details are held securely and will not be shared with your counsellor. This section is optional. GP name GP practice name GP practice address GP phone number Confirming your place Would you like to accept your place on the scheme? * Yes, I accept my place No, I am no longer interested Please confirm you have read the information sheet for your scheme *The information sheet explains what you can expect from the counselling programme. [Link to be added] Yes, I have read it No, not yet I have a question about the scheme If you have a question, tell us hereComplete this field only if you selected “I have a question about the scheme” above. Client AgreementPlease read the following agreement carefully. All boxes must be ticked to submit this form. As a participant I understand and agree that: I will receive up to 15 hours of counselling over 15 weeks, delivered online or by telephone I am responsible for scheduling my own appointments once I receive my counsellor's contact details I will not be charged for counselling sessions. Qualified counsellors are paid directly by TMAF. If I have been allocated to the Trainee Counsellor scheme, my counsellor is a trainee counselling psychologist enrolled on an accredited doctoral programme and registered with the HCPC as a student practitioner working under qualified supervision. They are not yet fully qualified practitioners and provide their services voluntarily as part of their professional training. My attendance will be monitored and I must notify TMAF promptly of any issues I may only request a change of counsellor within the first two weeks Missing or cancelling two consecutive sessions without notice may result in removal from the scheme. Where applicable a penalty of £90.00 may be charged I agree to complete a wellbeing evaluation upon completing my counselling sessions I can withdraw at any time with three weeks written notice Any disputes will be resolved informally and in good faith Yes, I have read and agree to the Agreement and the terms set out above I understand that missing two consecutive sessions without notice may result in removal from the scheme and a penalty of £90.00 I agree to complete a wellbeing evaluation upon completing my counselling sessions I agree to take part in any additional data collection requested by TMAF, funders or regulators Data ProtectionWe collect and store your personal information to administer the counselling scheme. Your data is held securely on UK-based servers. We will never share your personal information with third parties without your consent, except where required by law or in a safeguarding emergency. Your data will be retained for 7 years from the end of your participation (16 years for safeguarding records). You have the right to access, correct or request deletion of your data at any time by contacting counsellingsch@thelmamatildaalvesfoundation.com. I consent to my personal information being collected and stored by TMAF for the purposes of administering the counselling scheme Staying in touch Would you like to hear about future opportunities and events from TMAF? * Yes No Are you happy to be contacted for follow-up surveys or to share your experience anonymously as part of our impact reporting? * Yes No Client Registration Confirm your place on the 2026 Counselling Sponsorship Scheme.