Register your interest for more information and details on how to start your journey
LinkedIn
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First Name
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Email
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Type of counselling (select those which are appropriate)
(Required)
Sex Therapy
Relationship counselling
Compulsive Sexual Behaviour
Type of counselling
(Required)
Sex Therapy
Relationship counselling
Compulsive Sexual Behaviour
Consent
(Required)
I agree to the privacy policy.
(Required)
If you do not wish to take things further with Relate Jersey within 8 weeks of your enquiry, we will delete your enquiry form from our system.
Registration Form
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What service are you interested in
(Required)
Relationship counselling
Sex Therapy
CSB
Select as many as needed
What service are you interested in
(Required)
Relationship counselling
Sex Therapy
CSB
Do you require more information on Low Income Support
(Required)
Yes
No
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Do you require more information on
Low Income Support
Do you intend to attend counselling alone or jointly with your partner?
Alone
With my partner from the outset
With my partner eventually
Not sure
Name
(Required)
Email address
(Required)
Contact number
Address
(Required)
Street Address
Address Line 2
City
Postcode
Date of birth
You Partners Details
Your Partners Name
Your Partners Email address
Your Partners Contact number
Your Partners Address
Same as mine
Your Partners Address
Street Address
Address Line 2
City
Postcode
You Partners Date of birth
Please confirm which other agencies/services you are involved with (if applicable)
How many children do you have with your partner
How many other children do you have?(i.e. with former partners)
How many other children does your partner have?(i.e. with former partners)
How many children live with you full time or part time?
Does your partner know that you are contacting Relate?
Yes
No
Do you agree to us contacting your partner to arrange the joint assessment?
Yes
No
Please advise us when you would like us to involve your partner in the process. In the meantime, we will communicate with you alone.
