Family therapy referral form

Please complete the form below if you wish to arrange an Intake meeting. We’ll contact you by phone or email to arrange a date that suits you. Intake meetings cost £29 for a session and you will have an opportunity to discuss your contribution for regular appointments at the meeting.

We also offer family therapy where there are difficulties round separation and parenting.

If you are a solicitor acting on behalf of clients and family therapy has been recommended in court please use our referral form for solicitors.

Family member 1
Address
I/we would prefer sessions to be via:
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. Details will be stored for 7 years in accordance with GDPR.
Are you currently using any of our other counselling services?
Does any family member have any disability or access requirements?
Are both partners aware of this enquiry
Has domestic abuse ever been an issue?
Would both parents feel safe to discuss this together in counselling?
Please outline your availability for an Intake Meeting
Please note the Welcome Meeting is for adults only. Details of children/young people will be taken at the meeting. We will contact you to arrange a specific time and date.
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.