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BSL Questionnaire
Options
How would you like sessions paid?
NHS Funded
Self-Pay to Start & NHS Application
Self-Pay (Quick Start)
Access to Work
Employer Direct
Employment Support Company
School/University/College
CODA -Self Paid Only
Other
Other
Where do you live?
*
England
Wales
Scotland
Ireland
Other
Other
NHS Funding – England
We can apply for NHS funding within England. Some NHS regions are not supportive of specialist counselling. When you complete this form we will let you know if your NHS region is supportive or not.
NHS Funding – Scotland and Ireland
NHS Funding through DisabilityPlus is not a option. Please select self-pay if you would like to be supported by one of our team.
Self-Pay Session Fees
First Session £50 Every 3 Sessions after that is £180
How do you communicate?
BSL (only)
Oral & BSL
Oral CI user
Oral (not BSL)
Lip Reading
Spoken English
CODA-Spoken English
I would prefer not to say
Deafness
Deaf Since Birth
Acquired Hearing Loss (Medical)
Acquired Hearing Loss (Injury)
Acquired Hearing Loss (Other)
NHS Funding – CODA
NHS Funding is not available for CODA’s
Your Contact Details
First Name
*
Surname
*
Date of Birth
*
xx/xx/xx
Home Address
*
Mobile Number (Text)
Email Address
*
Your Doctor Details
Are you currently registered with a doctor
Yes
No
I would prefer not to say
Why?
Moved Address (Home)
Not Registered
I would prefer not to say
Surgery Name
*
Doctors Name, if known
Postcode
If you are human, leave this field blank.
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