Referral Form

Our counselling service is FREE for young people aged 11 to 19 years and up to 25 if you have special needs.

Services for adults are available from £10 per session. Find out more about costs here.

Services to schools are free and paid for. Schools referring young people can use this form. Find out more about school services here.

Others, including doctors, employers, parents or other care agencies can also use this form to refer a client.

To request counselling services for an individual please complete this form. We will get back to you within 14 days of your submission.


Details of person or agency referring a client:
Details of person or agency referring a client:
Details of client:
Details of client:
Date of Birth:
Date of Birth:
Address:
Address:
GP Address:
GP Address:
Counselling usually takes place face to face, but we can offer other options if you are interested. Please select one or more of the following: