Covid 19 - Questionnaire for Clients

This form must be completed before attending appointment


Before your appointment please:

  • Complete and return this Pre-Counselling Form before your appointment.
  • Inform the Rape Crisis North East Centre (RCNE) if there are any circumstances relating to COVID- 19, not included in this form, which you may need to be disclosed.
  • Self-isolate at home and contact your GP promptly for further advice if you have any COVID 19 symptoms.
  • Please stay at home until all symptoms have cleared following self-isolation.

To help prevent the spread of COVID 19 at RCNE, every worker, visitor and client must complete and sign this form before attending the Centre.

N.B. Every question MUST be answered.

Data Protection Statement

The personal information collected on this for, (which may include the collection of sensitive personal data) is collected for the purpose of ‘Prevention Of A Virus Contamination’ and continued high standard of good Hygiene practices and for the Health and Safety of employees/ clients and the business. Unless you direct otherwise, this questionnaire will be destroyed after 1 year.

Donate to Rape Crisis North East

We need your help to keep our organisation healthy to keep our front-line services in operation.
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