GP Surgery or Referring Organisation Referral GP or Referral Organisation Name * GP Surgery (if Known) Surgery or Referer Organisation Email Address GP Surgery or Referer Address (if known) Referred Client Address (if known) Referred Client Name * NHS Number (if known) Client/Patient Direct Contact Email Address Or Text Number * Reason For Referral * Submit Pricing is £95 per session, the Super6 is not eligible for organisation counselling.