Referral for Counselling

Due to excessive waiting times our referrals counselling is currently closed. We will continue to review this to ensure we can provide a timely response at a future date.

We can currently only accept referrals to Cairns in the Community for Patients of Woodside Medical Group.
Referral for Counselling

We provide individual counselling for anyone over the age of 18. Please complete all relevant sections of this form so that we can process your referral and place you on our waiting list. We are limited by insurance to provide counselling within the UK, and therefore cannot provide counselling to anyone located outside the UK even on a temporary basis.
Cairns Counselling is not an emergency service and cannot provide an urgent response to those in a crisis. If you do not feel safe, or are under threat, or need to talk to someone urgently, there are other services which may be able to help. A list of alternative support can be found by clicking the undernoted link.*

I confirm my referral is not for crisis supportI do not wish to proceed with a referral at this time
https://cairnscounselling.org.uk/wp-content/uploads/2021/11/Information-and-Support.pdf
We can only provide support at present to patients of Woodside Medical Group. Please confirm you are a patient of Woodside Medical Group.

Yes - I am a patient of Woodside Medical GroupNo - I am NOT a patient of Woodside Medical Group
If you are a patient of Woodside Fountain Health Centre, please enter your referral code here.*
Unfortunately we are unable to accept your referral at this time.

Due to excessive waiting times our referrals for donation based counselling is currently closed. We will continue to review this to ensure we can provide a timely response at a future date.

We can currently only accept referrals to our Cairns in the Community for Patients of Woodside Medical Group.
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Gender identity

MaleFemaleNon-binaryPrefer not to sayPrefer not to defineOther
Gender pronouns
What is your ethnic group, please choose the option that best describes your ethnic group or background

WhiteMixed or Multiple ethnic groupsAsian, Asian Scottish, or Asian BritishAfrican, Scottish African, British AfricanCaribbean or BlackOther ethnic group
Post code*
Email*
If you do not have an email, please type in aa@aaaa.com
Phone Number*
Please enter a valid phone number.Format: (00000-000000).
Are you currently receiving counselling elsewhere?*

NoYes
How did you hear about us?*

From my GPFrom another health professionalFrom a friend or family memberFrom another counselling serviceFrom another serviceSearch engine e.g. GoogleSocial media posts e.g. Facebook, InstagramOther
Please select all relevant items from the following list to tell us know a bit more about you and what brings you to counselling.*

AngerAnxietyBullyingDepressionProblems from childhoodBereavement or lossEating disorderDomestic abuseI have difficulty regulating my emotionsIssues in employmentFamily problemsGender identityPhysical health problemsIsolationI don't feel like myselfI take prescribed medication for my mental healthOCD or phobiasSubstance misuseAffected by another's substance misusePsychological abuseParenting worriesPost natal depressionRelationship problemsRacial abuse or discriminationStressSexual abuseSexual assaultLow self esteem or confidenceSelf harmSexualitySuicidal thoughtsTraumaRecent suicide attemptOther
We rely upon regular donations to provide your counselling. We would be grateful if you can consider making a regular contribution based on what your resources will allow. The following information will help provide a guide for your self-selected donation commitment. Please be reassured that you will have the opportunity to discuss this prior to counselling beginning. The amount and frequency of your donation will remain a choice.

Limited income, where you have to be careful to be able to pay for the basics you need. - £3 to £10 per sessionModerate income, where you can pay for everything you need but there is not much left over for luxuries. - £10 to £20 per sessionComfortable income, where you can easily pay for everything you need and have enough for a few luxuries. - £20 to £40 per sessionI am unsure
Is there anything else you think we should know?
Would you like to be kept up to date on Cairns Counselling?*

YesNo
Please verify that you are human*
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