Support Service Registration -

REGISTER AS ONE OF OUR SUPPORT SERVICE PARTNERS

If you are a counsellor or therapist operating in Sligo, Leitrim, Donegal, Mayo or Cavan and have a client(s) that would benefit from taking part in life-enhancing activities as part of their recovery process, then please fill out the form below and we will be in touch with you as soon as possible to confirm your registration.

SUPPORT SERVICES REGISTRATION FORM

Company/Service Name*

Make Company/Service Name visible on websiteYesNo

Therapist Name(s)*

Make Therapist Name(s) visible on websiteYesNo

Company/Service Phone Number*

Make Company/Service Phone Number visible on websiteYesNo

Company/Service E-mail*

Make Company/Service E-mail visible on websiteYesNo

Company/Service Postal Address*

Make Company/Service Postal Address visible on websiteYesNo

Address of Counselling Office(s) (If different from above)

Make Counselling Office(s) Address visible on websiteYesNo

Type of Counselling Provided*

Make Type of Counselling visible on websiteYesNo

Therapist(s) Qualifications*

Make Therapist(s) Qualifications visible on websiteYesNo

Therapist(s) Course(s) & University/Universities*

Make Therapist(s) Course(s) & University/Universities visible on websiteYesNo

Price Range of Services (e.g. €20-€40, €40-€60 or €60+ Per Session)*

Make Price Range of Services visible on websiteYesNo

Contact Hours*

Make Contact Hours visible on websiteYesNo

Can clients contact you directly or via their GP?*

Make Client Contact Route visible on websiteYesNo

Please provide names or contacts of any other Mental Health Support Offices that you feel may be interested in this service.

Additional Information

I agree that the above information is valid and up to date, and where I have indicated "Yes" Make Visible, this information will be published on the Havin' a Laugh website for information purposes.