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Counselling Referral Form

Online & Telephone counselling appointments available within 24 hours

Appointments are charged at

£40 per session

Full Name

Gender

Male

Female

Other

Phone

Town

Reason for seeking therapy?

Have you been formally assessed or diagnosed with:

Additional information:

Please select if...

You are or have in the last 2 years experienced suicidal ideations or feelings of wanting to self-harm

You have previously attempted suicide or self-harmed (within the last 2 years)

Which day(s) are you available?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Which time(s) are you available?

Morning (9am-noon)

Early Afternoon (noon-3pm)

Late Afternoon (3pm-6pm)

Evening (After 6pm)

Please confirm if you have a preference on the gender of your counsellor

Male

Female

Please confirm your preferred session method(s)

Telephone

Video (Google Meet)

Where did you hear about us?

Other:

I am happy to receive information about Mental Health (Support, News, & Resources) from TCS in the future.

Online & Telephone counselling appointments available within 24 hours

Appointments are charged at

£40 per session

Before you submit your referral please tick here to consent to storage and processing of your data

07895 796857

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