Simple Therapy - Hammmersmith & Fulham Referral Form

Simple Therapy - Referral Form

Hammersmith & Fulham Project
Simple Therapy A FREE counselling service for young people and adults.

Who is this service for?

Hammersmith and Fulham residents living in the following wards: Addison, Avonmore, Brook Green, College Park & Old Oak, Coningham, Grove, Hammersmith Broadway, Ravenscourt, Shepherd’s Bush Green, Wendell Park, White City, Wormholt

Aged 18 and above

People who are able to commit to weekly face-to-face counselling sessions
Where did you hear about Simple Therapy? *
Name*

First NameLast Name
Pronouns*
Date of Birth*

MonthDayYear
Date
Age*
Which of the following wards do you live in?*
Address*

Street Address

Street Address Line 2

CityCounty

Postcode
Telephone Number*
Email*
example@example.com
Preferred form on contact*
YesNo
YesNo
If yes, please state the name of the medication you are taking.
YesNo
If yes, please provide the date you were hospitalised and the duration.
Anxiety/Anxiety DisordersADHD/ADDBereavement & LossChildhood TraumaDepressionDomestic AbuseFemale Genital Mutilation/Cutting (FGM/C)Family ConflictLow Self-EsteemLife Changes and TransitionsPregnancy, Prenatal, and Postnatal DepressionPoor Physical HealthRelationship DifficultiesRapeRacial Trauma/Social InjusticeSeparation and DivorceSuicidal IdeationSexual AbuseSexual AssaultSelf-HarmSexualityTraumaWork-Related StressOther
Please tell us what you would like to achieve from the counselling sessions
What time of the day would you prefer to have counselling sessions?*
Please Note: We will do our best to accommodate your request, however, we cannot guarantee that you will be offered your first choice.
YesNoPrefer not to say
If yes, please state if you require specific support or assistance in aid of your counselling sessions
MaleFemaleTransgenderNon-Binary/Non-ConfirmingPrefer not to say
Sexual Orientation*
Ethnicity *
Occupation/Employment Status:*
Please verify that you are human*
Thank you for completing the Simple Therapy referral form. Once submitted you will be contacted via your preferred form of contact to discuss things further.
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Simple Therapy - Referral Form