North Lynn Industrial Estate
Tel. 01553 770770
REMOTE SERVICES FOR COUNSELLING Self-Referral Form – Use this form if you would like to request a service for yourself. (Please complete all boxes)
Please provide all contact details and state your preferred method of contact
Please tick (a), (b), (c) if you do not give permission.
If yes, please give details: (Please note that the One to One Project is not a crisis service. In the event of current thoughts of suicide, please contact Samaritans on 116 123 or the Crisis Team on 0300 790 0371 if you are already a Trust user)