Counselling Referral Form

Please complete the form below to make a referral to our counselling team. Once the completed form has been submitted, we will be in touch with you within 48 hours to arrange scheduling the first session.

Referral For
Name *
Referral Submitted By
Responsible Adult Contact Details - in case of emergency
Session Funding
If not applicable please type N/A
Confirm initial commitment to 6 therapy sessions *
Session Preferences
Preferred location for therapy *
For example - Weekdays after school, Monday afternoon between 3 and 5pm or weekends
Please provide a brief overview as to the reasons for making the referral.