Referral

The Bridge Counselling Service is currently open for new referrals. We operate on a self-referral basis only.

If you would like to access counselling, please complete the self-referral form below and press "submit". Please be sure to complete all sections including data consent.

Upon receipt of your completed self-referral form, you will be sent a follow-up questionnaire.

Once we receive your completed questionnaire, one of the team will be in contact to arrange an appointment for you to have an initial consultation with one of our counsellors.

Please note that completing this process is not a guarantee of counselling but will allow an informed decision to be made together as to whether counselling is the right approach for you at this time.

All information you supply will be treated in strict confidence, as detailed in our Privacy Policy.

Please note:

Counselling sessions are not free. We operate a low cost donation based service, we suggest a minimum donation of £20. This does not apply to the assessment process but will begin once regular counselling sessions are agreed.
At present, our counselling service is limited to daytime hours only, (Monday to Thursday 9am to 5pm).

Name*

First Last

Gender*

Male
Female
Other

Date of Birth*

Please note, you must be at least 18 years old to use our services

Address*

Street Address City Post Code

Can we send letters to this address?*

Yes
No

Phone*

Mobile*

Email*

We will assume we can email you about counselling to this address.

If you don't have an email address, please type in noreply@gmail.com.

Can we leave a message on your phone?*

Yes
No

Do you have any additional support requirements?*

Yes
No

Please give further details

How did you hear about Bridge Counselling? Please select an option.*

Complete if you selected "other" above

Your Data*

Accept Data Protection Policy

We are committed to keeping your data safe and sound. Find out how your data will be used by reading our privacy policy. If you are happy to continue, please check the box above.

Counselling Self Referral Form