Anxiety Action Wales - Referral Form

Counselling Referral Form

CONFIDENTIAL
To begin the counselling process please complete and return this Referral Form

Currently our counselling service is only available online or by telephone.

Once we have received your completed referral form we will contact you to arrange an assessment where we will agree the optimum therapeutic approach, counsellor and timing which meets your individual requirments.
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City County

Postcode
Email Address *
Preferred Contact Number *
Please enter a valid phone number.
Alternate Contact Number
Please enter a valid phone number.
Let us know if there any contact restrictions / issues that we should be aware of
Gender

Female Male Prefer Not to Say Select to Self Describe...
Ethnicity

Choose one of the below ethnicities that you feel best describes you
White

Welsh, English, Scottish, Northern Irish or British Irish Gypsy or Irish Traveller Any other White background
Mixed or Mutiple ethnic groups

White or Black Caribbean White and Black African White and Asian Any other Mixed or Multiple ethnic background
Asian or Asian British

Indian Pakistani Bangladeshi Chinese Any other Asian background
Black, African, Caribbean or Black British

African Caribbean Any other Black, African or Caribbean background
Other ethnic group

Arab Any other ethnic group
Next of Kin Name

First Name Last Name
Next of Kin Address

Street Address

Street Address Line 2

City County

Postcode
Next of Kin Phone Number
Please enter a valid phone number.
Name of GP

First Name Last Name
GP Address

Surgery Name

Street Address

City County

Postcode
GP Phone Number
Please enter a valid phone number.
Name of NHS Mental Health Service Contact / Social Worker

First Name Last Name
NHS Department
Phone Number
Please enter a valid phone number.
If you are completing this referral form for someone else please complete your contact details below. To proceed we will need the person to sign this form to give their consent.
Referrer Name

First Name Last Name
Referrer Organisation
Referrer Contact Number

Area Code Phone Number
Any additional information that, as the referrer, you feel is relevant
What is the issue that you are seeking counselling for? *
What are you hoping your counselling achieves?
Are you taking and prescribed medication? If Yes, please list below
Have you had any thoughts of harming yourself or others? If yes please provide more details
Is there anything else you think we should know / be aware of?
Please select any of the below that you are experiencing

Anxiety Anxiety / Panic Attack Anger Academic Difficulties Bereavement / Loss Body Dysmorphia Bullying Depression Domestic Violence Eating Issues Emotional Abuse Family Difficulties Family Separation / Divorce Financial Difficulties Obsessive / Compulsive Issues Phobia/s Physical Health Issue/s Physical Abuse Post Traumatic Stress Relationship Difficulties Self-Harm Self Worth / Self Esteem Sexual Abuse / Assault Sexual Identity Issues Sleeping Difficulties Stress Suicidal Thoughts Substance Abuse / Addictions Trauma
How did you hear about Anxiety Action Wales CIC

Google Twitter LinkedIn Facebook Word of Mouth Counselling Directory Other
Thank you for completing this form

How to return to us -

Email: Info@AnxietyAction.Org

or

Post: Anxiety Action Wales, Garn Farm, Wenvoe, Cardiff, CF5 6BE

Once we receive your form we will contact you within 3 working days to book your assessment.

By completing this form you acknowledge and accept that Anxiety Action Wales will hold and process in accordance with GDPR your personal data as necessary to provide our counselling service.
Signature *

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Counselling Referral Form