BSL Questionnaire BSL Questionnaire Counsellor How do you communicate? BSL (only) Oral & BSL Oral CI user Oral (not BSL) I would prefer not to say Preference of Counsellor Male Female Either I would prefer not to say How would you like sessions paid? Self-Paying NHS Funded Self-Pay to Start Health Assured Hearing Loss Cornwall Continued? School Wellbeing Service Hearing Loss Cornwall Wellbeing Solutions OtherOther Your Contact Details First Name * Surname * Home Address * Date of Birth xx/xx/xx 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 GP Practice? * GP Phone Number If known Doctors Name, if known Postcode Next
