Telephone and Online Couples Counselling Referral Form - Over 18

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 via bank transfer’ 48 hours prior to your appointment and in-line with our cancellation policy.

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

Email Address:
Date of Birth
2nd Client Name
2nd Client Date of Birth
Maritial Status
Are you employed?

Combined Income
Are you in receipt of benefits?

Ethnic Origin
2nd Client Ethnic Origin
Home Phone
Ok To Leave Message

Mobile Phone
2nd Client Mobile (optional)
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
Referrer's Phone No
Referrer's Email
Date of Referral
Where did you hear about our service
If your sessions are due to be funded by an organisation, please give details (Contact Name, Phone, Email, Purchase Order No, Invoice Address and No of Sessions if known)

Using your personal information

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

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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