Self Referral

Please fill in the details below and press submit for a counsellor to make contact and assess how we can best support you.

Basics

Preferred Pronouns

First Name *

Surname *

Date of Birth *

Gender

Ethnicity *

Sexuality *

Any Disabilities *

Telephone *

Email *

Address *

GP Surgery Name *

Emergency Contact Name *

Emergency Contact Number *

Any Medications *

Any Previous or Current Mental Health Diagnosis *

History

Have you ever or are you currently struggling with a dependency with alcohol or drugs *

Have you ever or are you currently struggling with any other form of dependency or addiction *

Have you ever experienced any childhood trauma *

Have you ever been a victim or witness of domestic violence *

Additional Comments

Availability

Which days are you available to receive counselling *

Which days are you 100% not available to have a counselling session *

Would you prefer an AM session or PM session *

How would you like to receive counselling

Face to Face

Telephone

Video Calls

What would you like to achieve through receiving counselling *

How did you hear about us *

How would you prefer we contact you? *

Log In

0 items £0.00

Ratcliffe Therapeutic Counselling | ASIST Trained Crisis Support | Social Prescribing UK | Forces Specialists UK

Self Referral

Self Referral

Basics

History

Availability

Quick Links

Log In 0 items £0.00

Ratcliffe Therapeutic Counselling | ASIST Trained Crisis Support | Social Prescribing UK | Forces Specialists UK

Self Referral

Self Referral

Basics

History

Availability

Quick Links

Follow Us

Log In

0 items £0.00