Complete the following referral form to submit a request for counselling
Please select any special requirements you might need (Select all applicable)
Please select mode of service preferences
Please select a referral source from the list below.
Select one or more of the issues you are experiencing.
Please select your GP from the list below.
If your general practitioner doesn't exist in the list above tick this checkbox and complete the new GP form.
Please select your referrer from the list below.
If your referrer doesn't exist in the list above tick this checkbox and complete the new referrer form.
We may use client information to carry out our obligations arising from any contracts entered into by the client and us. We promise to keep your details safe and secure. We will not share your information with third parties for marketing purposes. We may contact you to let you know about other services, events or for evaluation purposes.
The circumstances when details can be shared include:
We would ask that you keep us informed (by email, telephone, or in writing) of any changes in your personal data so that we may have our records up to date at all times. If you wish to withdraw your consent please contact us (by email, telephone, or in writing). You have the ‘right to be forgotten’, which means you can request the deletion or removal of personal data where there is no compelling reason for its continued processing.
By removing a Tick above we will not contact you via this method.