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

Self-Refer to North East Counselling Service (2024)

Couples 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 individually please fill out the individual form.
Your Name

First NameLast Name
Your Partner's Name

First NameLast Name
Your Date of Birth

DayMonthYear
Date
Your Partner's Date of Birth

DayMonthYear
Date
What is your Address?

Street Address

Street Address Line 2

Town/CityCounty

Post Code
Please provide one E-mail address
example@example.com
Please provide one mobile number
Format: 00000000000.
Which of these best describes your main worries? (Please tick as many as apply)
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?
Your GP's Name

First NameLast Name
Your Partner's GP's Name

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Partner's GP's Surgery Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your GP's Contact Number
Please enter a valid phone number.Format: 0000 000 0000.
Your Partner's GP's Contact Number
Please enter a valid phone number.Format: 0000 000 0000.
We give North East Counselling Service permission to contact us via:
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)