Leukaemia Counselling Service – Online Application Form

Surname:

First name:

Title:

Email address:

Contact telephone number:

Home address:

Gender:

Date of birth:

Hospital and name of consultant where you/your family member are being treated

Relationship to the patient if a family member:

Diagnosis

Why are you seeking counselling?

Were you offered counselling on the NHS?

Have you undergone counselling on the NHS for the same issues?

What do you hope to achieve by the end of your sessions?

Do you need help finding a counsellor?
YesNo
If you have identified a suitable counsellor, please provide their name, address, phone, email and registration number for either the BACP or the UKCP. We will check their membership with the relevant body

Share your story

If you wish to share your story of diagnosis or supporting someone with a blood cancer, please let us know and we will get in touch with you. We use stories to show our impact to supporters but also in campaigning work to improve the lives of people affected by blood cancer.

I would like to share my story

Application agreement

I confirm I have read the terms and conditions and agree to abide by them. I also agree to provide written feedback once I have received the grant.

On submitting this form, you will automatically be enrolled in receiving our email communications about our services, campaigns, volunteer opportunities, and how to get involved.

Name:

Date: