Individual counselling referral

Please complete the form below if you wish to arrange an Individual intake meeting. 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’re looking to attend with a partner please complete a Couple Counselling Referral. 

Name
Address
I 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 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?
Do you have any disability or access requirements?
If you are in a relationship, does your partner/s know about your enquiry
Has domestic abuse ever been an issue?
Would you feel safe discussing this in counselling sessions
Please outline your availability for an Intake Meeting
We will contact you to arrange a specific time and date.