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The Self-Referral
Aspirations?
Multi-select
Facilitating behaviour change
Enhancing coping skills
facilitating your potential
Development of self-worth
Improving relationships
Reduce anger
Reduce negative feeling and thoughts
Explore broad set of issues
Reduce or remove addictions
Establish and maintain relationships
Remove or reduce negative cycles
Other
Other
What Would You Like Help With?
Multi-Select Available
Addictions
Anger
Anxiety
Body Dysmorphia
Chronic Fatigue Syndrome
Chronic Pain
Depression
Dissociative Disorders
Health Anxiety
Fibromyalgia
OCD
Continued
Psychosis
Panic Disorder
Personality Disorder
Phobias
PTSD
Social Anxiety
Stress
Suicidal Thought
Self-Harm Thoughts
Other
Other
Address & Contact
Your Name?
*
PostCode?
*
Date of birth?
*
You would like?
Pay-Privately
Pay-Privately to Start & NHS Application
NHS Application
Employer Support
Legal Referral
Other
Other
NHS Application
NHS Application’s rate of success depends on your location. The standard timescales are 8 weeks from when your GP sends our application to the funding panel.
Pay Privately & NHS Application
Paying privately allows you to start counselling quickly. When this form is completed, we will arrange your counselling. Fees Introduction Session £50 Pay-as-you-go £70 Saver3 (3 sessions) £180 NHS Application’s rate of success depends on your location. The standard timescales are eight weeks from when your GP sends our application to the funding panel.
Pay Privately
Paying privately allows you to start counselling quickly. When this form is completed, we will arrange your counselling. Fees Introduction Session £50 Pay-as-you-go £70 Saver3 (3 sessions) £180
GP Details
Surgery Name
Postcode
Dr Name (if Known)
Home?
Relationship?
Single
Divorced
Live-In-Partner
Married
Children?
Yes
No
Employment?
Employed?
Yes
No
Status
Full-Time
Part-Time
Are You Medically or Physically Able to Work?
Yes
No
Other
Other
Are You Retired?
Yes
No
Are you a student?
Yes
No
If you are human, leave this field blank.
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