Warning, Javascript has been disabled, this form will not function correctly.
Client Surname*
Client First Name*
Address line 1*
Address line 2
Town*
Locality*
Postcode*
Email Address
Landline Telephone No.
Mobile Telephone Number (parent/carer contact number if referring a child or young person under 18)*
Contact by Letter?*
Contact by Email?*
Contact by SMS?*
Consent to leave a Voicemail*
Date of Birth*
Are you currently receiving support from any other services?*
Please specify which service you are receiving support from?
Do you have a mental health diagnosis from a GP or Health Care Professional?*
Please specify
Have you or the person seeking Counselling had a bereavement?*
Name of the person who has died*
What is their relationship to you/ the client?*
Main cause of death*
Other - please specify
Month of Bereavement*
Year of Bereavement*
Referrer's First Name
Referrer’s Last Name
Referrer's Contact Number
Referrer's Email address
Relationship/Referring Organisation
Parent/Carer Name (if under the age of 18)
Have you obtained the consent of the person to make this referral?