Client Referral Form

Please fill out the form below. For any fields that are not applicable please enter N/A.

When giving income you must include any benefits you are in receipt of.

Any session prices quoted below are purely a guide as some complex counselling needs and under 18s will attract a higher fee.

Sessions are payable by cash only and we ask that you bring the correct fee with you, as we do not keep change on site.  

Cancellation policy is 48 hours notice - if outside of this then the session fee is still payable.

If you require the couple referral form or children's referral form then please click on the button below.

Client Couples Referral Form Client Childrens Referral Form

Email Address:
Date of Birth
Maritial Status
Are you employed?

Are you in receipt of benefits?

Total Income (including benefits)
Ethnic Origin
Home Phone
Ok To Leave Message

Mobile Phone
Ok to Leave Message (Mobile)

Reason for referral
Please give details of any identified risk issues
Current Medication
Is there any substance history, past or present, if so please list history/problems and amount. Substance relates to alcohol, drugs and prescribed drug addiction, misuse and habits etc.
Please give details of any current/previous involvement with GP/Health Professional/other services including dates if known.
GP Practice & Registered Doctor
Referrer's name
Referrer's Title
Referrer's Organisation
Referrer's Position
Date of Referral
Where did you hear about our service

Using your personal information

Personal information which you supply to us may be used in a number of ways, for example:

  • We will use the information you give to help provide the services/products you have requested that we supply to you.
  • From time to time information may need to be accessed by our website and hosting providers to ensure the smooth running of the services we provide.
  • We will not disclose any information to any company outside the above mentioned scenarios except to help prevent fraud, or if required to do so by law

For further information on how your information is used, how we maintain the security of your information, and your rights to access information we hold on you, please visit