Couple counselling referral

Please complete the form below if you wish to arrange an Intake meeting for you and a partner. We’ll reach out to you by phone or email to arrange a specific date. Intake meetings cost £29 for a session and you will have an opportunity to discuss your contribution for regular appointments at the meeting. If you are looking to attend on your own you can complete an Individual Referral.

Name
Address
We would prefer sessions to be via:
To conform with GDPR your partner must be aware that we will have their email address. If you are supplying this information please tick the box below.
I have permission to give you my partner's email address
I am able to receive contact by:
We will use these details to contact you about available appointments and will not share any clinical or personal data through them. Typically we will use your contact details only to confirm appointments and they will not be shared with your counsellor. Details will be stored for 7 years in accordance with GDPR.
Are you currently using any of our other counselling services?
Are both partners planning to attend an Intake Meeting together?
If not we can arrange an individual Welcome Meeting for you both separately, and make an arrangement from there.
Do you have any disability or access requirements?
Are both partners aware of this enquiry
Has domestic abuse ever been an issue?
Would you feel safe to discuss this together in counselling?
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