top of page
Crisis Resources
info@lanterncounselling.org
077395756069
Accessibility Form
First name
*
Last name
*
Email
*
Phone
Birthday
Day
Month
Year
GP Address
Access to the Space (Mobility and Physical Needs)
Step free access required
Wheelchair user
Need for seating adjustments (e.g. firm chair, extra space)
Need for breaks during sessions
Need quick access to a bathroom
Other or additional details (please specify)
Sensory Environment
Sensitive to noise
Sensitive to lighting (e.g. bright lights, fluorescent lighting)
Prefer low lighting
Prefer minimal visual distractions
Sensitive to smells
Prefer silence/minimal background noise
Other or additional details (please specify)
Communication and Language Needs
English is not my first language
I may need extra time to process or respond
I prefer clear, simple language
I may struggle to find words / go non-verbal at times
I prefer written follow-up or summaries
Other or additional details (please specify)
Visual and Hearing Needs
I am visually impaired or have low vision
I am blind
I am deaf or hard of hearing
I use hearing aids or assistive listening devices
I rely on lip reading
I would benefit from clear visibility of your face (e.g. good lighting, facing me directly)
I may need written information alongside spoken communication
I use British Sign Language (BSL) or another sign language
I may require an interpreter (please specify)
Other or additional details (please specify)
Neurodiversity and Processing
I am neurodivergent (diagnosed or self-identified)
I may need structure or predictability
I may need support with focus or pacing
I may experience overwhelm or shutdown
Other or additional details (please specify)
Trauma Awareness and Triggers
Certain topics feel overwhelming (you can specify if you wish)
I may dissociate or feel disconnected at times
I may need grounding support during sessions
I prefer to go slowly when discussing difficult experiences
I would like check-ins during sessions
Other or additional details (please specify)
Are there any aspects of your identity that you would like me to be aware of in order to support you better? (This might include culture, religion, gender identity, sexuality, disability etc.)
Practical Adjustments
Preference for online sessions
Preference for in-person sessions
Flexible session length (where possible)
Regular breaks during sessions
Consistent session structure
Other or additional details (please specify)
Is there anything else you would like me to know to help make counselling feel safer or more accessible for you?
Submit
bottom of page