ÿþ<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd"> <html xmlns="http://www.w3.org/1999/xhtml"> <head> <link rel="stylesheet" href="screen.css" type="text/css" media="screen" /> <link rel="stylesheet" href="print.css" type="text/css" media="print" /> </head> <body bgcolor="#CFE7DB"> <div> <p>This form can be competed online and send to Philippi or you can <input type="button" onClick="window.print()" value="Print This Page"/> and send the completed form by post to the address below.</p> <table> <tr> <td width="250px" > <img src="philippi.gif"></td> <td> 233 Kings Road, Reading, Berkshire RG1 4LS <br /> Tel: 0118 966 7422 <br /> Email: reading@philippitrust.freeserve.co.uk <br /> Registered Charity Number 1016105 <br /> </td> </tr> </table> </div> <div> <br /> <H1>Application for Counselling - CONFIDENTIAL</H1> <form method="post" action="/cgi-bin/mailform.pl"> <input type="hidden" name="recipient" value="reading@philippitrust.freeserve.co.uk" /> <input type="hidden" name="return_link_title" value="Return to Philippi Trust" /> <input type="hidden" name="return_link_url" value="http://www.philippireading.org.uk/" /> <input type="hidden" name="required" value="FullName, email" /> <table border="0px" width="650px"> <tr> <td width="110px">Title:</td> <td colspan="1"><input type="text" size="10" name="Title"></td> <td width="100px">Full Name: </td> <td colspan="2"><input type="text" size="47" name="FullName"></td> <tr> <td>Address:</td> </tr> <td colspan="5"><textarea name="Address" rows="5" cols="78"></textarea></td> </tr> <tr> <td>Post Code: </td> <td colspan="2"> <input type="text" size"10" name="Postcode"></td> </tr> <td>Tel No:</td> <td colspan="1"><input type="text" size="20" name="TelephoneNo"></td> <td></td> <td ALIGN="right">Mobile: </td> <td colspan="2"><input type="text" size="20" name="MobileNo"></td> </tr> <tr> <td>Email: </td> <td colspan="4"><input type="text" size="87" name="email"></td> </tr> <tr> <td height="17px"></td> </tr> <tr> <td>Occupation:</td> <td colspan="2"><input type="text" size="35" name="Occupation"></td> <td ALIGN="right">Age:</td> <td colspan="2"><input type="text" size="20" name="Age"></td> </tr> <tr> <td height="17px"></td> </tr> <tr> <td>Family Details:</td> <td colspan="4"><input type="text" size="87" name="FamilyDetails"></td> </tr> <tr> <td height="17px"></td> </tr> <tr> <td>Doctor: </td> <td colspan="4"><input type="text" size="87" name="Doctor"></td> </tr> <tr> <td height="17px"></td> </tr> <tr> <td colspan="3">Have you ever suffered any serious medical problems?</td> <td width="80px"><input type="radio" name="MedicalProblems" value="yes" /> Yes</td> <td width="80px"><input type="radio" name="MedicalProblems" value="no" /> No</td> </tr> <tr> <td>details:</td> <td colspan="4"> <textarea name="DetailsMedicalProblems" rows="3" cols="66"></textarea></td> </tr> <tr> <td height="17px"></td> </tr> <tr> <td colspan="3">Have you ever suffered from any form of psychiatric illness?</td> <td><input type="radio" name="psychiaticIllness" value="yes" /> Yes</td> <td><input type="radio" name="psychiaticIllness" value="no" /> No</td> </tr> <td>details:</td> <td colspan="4"> <textarea name="DetailsPsychiatricIllness" rows="3" cols="66"></textarea></td> </tr> <tr> <td height="17px"></td> </tr> <tr> <td>Prescribed drugs</td> <td colspan="4"> <textarea name="PrescribedDrugs" rows="3" cols="66"></textarea></td> </tr> <tr> <td height="2-px"></td> </tr> <tr> <td height="17px"></td> </tr> <tr> <td colspan="4">Other information you think we ought to be made aware of:</td> </tr> <tr> <td colspan="5"> <textarea name="OtherInformation" rows="4" cols="77"></textarea></td> </tr> <tr> <td height="17px"></td> </tr> <tr> <td colspan="3">Previous Counselling:</td> </tr> <tr> <td colspan="5"> <textarea name="PreviousCounselling" rows="4" cols="77"></textarea></td> </tr> <tr> <td height="17px"></td> </tr> <tr> <td colspan="3">How would you define your problem?</td> </tr> <tr> <td colspan="5"> <textarea name="DefineProblem" rows="8" cols="77"></textarea></td> </tr> <tr> <td height="17px"></td> </tr> <tr> <td colspan="3">How do you see us being able to help?</td> </tr> <tr> <td colspan="5"> <textarea name="HowHelp" rows="5" cols="77"></textarea></td> </tr> <tr> <td height="17px"></td> </tr> <tr> <td colspan="3">How were you made aware of Philippi?</td> </tr> <tr> <td colspan="5"> <textarea name="AwarePhilippi" rows="5" cols="77"></textarea></td> </tr> <tr> <td height="17px"></td> </tr> <tr> <td colspan="3">Do you have any special requirements?</td> </tr> <tr> <td colspan="5"> <textarea name="SpecialRequirements" rows="5" cols="77"></textarea></td> </tr> <tr> <td height="17px"></td> </tr> <tr> <td colspan="5"> If you have a strong preference for either a male or a female counsellor,<br /> please state your preference here (Please be aware this may affect the waiting time) </td> </tr> <tr> <td colspan="5"> <textarea name="CounsellorPreference" rows="5" cols="77"></textarea></td> </tr> <tr> <td height="17px"></td> </tr> <tr> <td colspan="5">Please indicate days, times and telephone numbers where we can contact you:</td> </tr> <tr> <td colspan="5"> <textarea name="ContactDayTimeNo" rows="5" cols="77"></textarea></td> </tr> <tr> <td height="17px"></td> </tr> <tr> <td colspan="3"><b>Are you happy for us to leave messages on your answer phone?</b></td> <td><input type="radio" name="answerphone" value="yes" /> Yes</td> <td><input type="radio" name="answerphone" value="no" /> No</td> </tr> </table> </br></br> <table width="650px"> <tr> <td colspan="7">When would be the most suitable times for counselling? Please give as many choices as possible:- </td> </tr> <td width="150px"><b>Tuesday</b></td> <td>Morning</td> <td width="100px"><input type=checkbox value=Yes name="Tuesday_Morning"></td> <td>Afternoon</td> <td width="100px"><input type=checkbox value=Yes name="Tuesday_Afternoon"></td> <td>Evening</td> <td><input type=checkbox value=Yes name="Tuesday_Evening"></td> </tr> <tr> <td><b>Wednesday</b> <td></td> <td></td> <td>Afternoon</td> <td><input type=checkbox value=Yes name="Wednesday_Afternoon"></td> </tr> <tr> <td><b>Thursday</b></td> <td>Morning</td> <td><input type=checkbox value=Yes name="Thursday_Morning"></td> <td>Afternoon</td> <td><input type=checkbox value=Yes name="Thursday_Afternoon"></td> <td>Evening</td> <td><input type=checkbox value=Yes name="Thursday_Evening"></td> </tr> <tr> <td height="17px"></td> <tr> <td colspan="7"><i>If you have any difficulties at all in completing this form, please telephone the office and we will offer you all the help we can </i></td> </tr> </table> <br /> <input type="submit" value="Email This Form" /> <input type="button" onClick="window.print()" value="Print This Page"/> </form> </div> </body> </html>