Confidential Referral Form - New Life Counselling

To access counselling you can complete this referral form.  You can complete this yourself, or this can be done for you by a family member, GP, Social Worker or someone else.  The information is confidential.

Your referral will not be picked up over the weekend or at times when our offices are closed (please remember that our offices are closed between 5pm Friday 23rd December and 8.30am Tuesday 3rd January).  If you need support urgently please contact Lifeline on 0808 808 8000.


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Full Name
Date of Birth
Address
Postcode
Name of Parent/Guardian(if under 16)
Telephone Number
Email Address
Referring to
Current School Attended
Are Ground Floor facilities required?
Have you used this service before?
How did you hear about the service?
Tell us the situation for which you require counselling, inc Family/Medical past
Please tick if you are affected by any of the following
..
Other
Are you asking for help for yourself
If you are referring for family support please give details of family members
Referrer Name
Referrer Organisation
Referrer Position
Organisation Address
Organisation Postcode
Organisation Telephone Number
Organisation Type
Other (Please Specify)
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