Referral Form

To access counselling, please complete the quick form below and then click submit. A member of our team will then contact you, usually within 24 hours.

First Name(required)

Last Name

How do you identify in terms of your gender/what are your preferred pronouns? (required)

Date of Birth(required)

Email(required)

Phone Number(required)

House Number and Street [first line of address](required)

Town(required)

Post Code(required)

We know some people prefer to see a counsellor of a particular gender and where possible we can try to accommodate this, please indicate your preferences below:(required)

Briefly, in just a few words, would you like to tell us what you would like to cover during your therapy?

Before you click submit, please confirm the following:(required) I confirm that I have read and agree to all the terms and conditions of service listed on this site.

I am aware that this service is provided free based on my being on benefits and/or a low income and that I am happy to provide evidence of this.