Self-Referral

Privacy Statement

First Name

Surname

Gender Gender

Date of Birth

00/00/0000

Email

Phone Number

Post Code

What are you referring for?

Self-Paid Counselling (Immediate Start)

Self-Paid & Free Funding Application

Free Funding Application Only

Other

Funding Applications can be made for:

If your disability is not shown here free funding is not available

Self-Paid Counselling

First Session = £50
Saver 3 Plan = £180 for 3 Sessions (£60)
Pay-as-you-go = £70

What is your NHS region?

Place, example NHS Wakefield, Lambeth etc

Any Previous, NHS Counselling? Any Previous, NHS Counselling?

If yes, what year approximately?

Have you ever been discharged as unsuitable by NHS counselling? Have you ever been discharged as unsuitable by NHS counselling?

Disability A-F

Disability G-V Disability G-V

Acquired Injury Acquired Injury

Genetic Disease/Disorders Genetic Disease/Disorders

Medical Interventions Medical Interventions

Carer Carer

For Who?

What would you like help with?

Continued

Confidentiality

Although we are asking for GP details, we will never contact your GP unless you ask us to or give us permission.

Practice Name

Practice Postcode or Town

What would you like help with?

Write in here anything you want to tell us.