Self-Refer (Individual) to North East Counselling Service (2024)

Self-Refer to North East Counselling Service (2024)

Individual Application
Often it isn’t until you have gone home that you start to reflect on the journey you have had. Please do not hesitate to reach out, taking care of yourself is just as important as caring for your baby.

If you've returned home from the Unit, you can benefit from 6 free counselling sessions from the North East Counselling service. If you feel this is something you would benefit from, please fill in the form below and a Tiny Lives staff member will be in touch to get the process started.

This can be as an individual or as a couple - whatever works best for your family.
If you'd like to take part as a couple, please fill out the couples form.
Your Name*

First NameLast Name
Your Date of Birth*

DayMonthYear
Date
What is your Address?*

Street Address

Street Address Line 2

Town/CityCounty

Post Code
E-mail*
example@example.com
Mobile Number*
Which of these best describes your main worries? (Please tick as many as apply)*

AttachmentAnticipatory griefAnxietyAngerBereavement/lossCarer responsibilitiesChild with a disabilityCovid causedCovid exacerbatedDepressionExhaustionFearFlashbacksFrustrationGriefIsolationLow confidenceLow moodOCDPanic attacksPTSDSelf-worth/self esteem
What dates were you on the Neonatal Unit? *
What is your child's name? (For multiples please use the same box)
What gestation was your little one?*
Have you previously been in contact with clinical psychology or perinatal mental health teams for support? If so, please advise the approximate dates of this support
Do you have any recent medical/family history that may impact how you're feeling?
When are you available? (Please provide times/dates if possible)
Your GP's Name*

First NameLast Name
Your GP Surgery's Name*
Your GP Surgery's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GP Contact Number*
Please enter a valid phone number.
GP Email
example@example.com
I give North East Counselling Service permission to contact me via:*

I consent that I'd like to receive emails from NECI consent that I'd like to receive SMS texts from NECI consent that I'd like to receive letters from NECI consent that I'd like to receive phone calls from NEC and they can leave voice messages
Your data will remain held in the tightest confidence by Tiny Lives and shared only with the North East Counselling Service (who will be running your counselling session). They may share information with your GP.*
Should be Empty:

Self-Refer to North East Counselling Service (2024)