Referral

The Bridge Counselling Service is currently open for new referrals.

If you would like to arrange an initial consultation session we require you to complete the following form. All information you supply will be treated in strict confidence, as detailed in our Privacy Policy, but you do need to consent to us holding and processing your data.

Please note that completing the form is not a guarantee of counselling but it will allow us to move towards the allocation of an initial consultation where we can have a discussion with you about whether counselling would be a good way forward for you at this time.

Once received we will be in contact with a potential date for the initial consultation.

Please note: our counselling service is limited to daytime on Mondays, Tuesdays (very limited) and Wednesdays, and daytime and evening on Thursdays.

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 Address Line 2 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

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