Referral Form

NAME*
Please type your first name and last name
Reference Number
If you have been given a reference number please add it here.
ADDRESS*
House number/name and street name
POST CODE
DATE OF BIRTH

DayMonthYear
Date
CONTACT PHONE NUMBER*

Area CodePhone Number
Email Addresss*
Can messages be left?*

YesNo
Do you have a preference for Face-to-face, Phone or Video for your initial assessment?*

Face-to-faceVideo (Zoom)Telephone
G.P. Practice
Surgery or Doctor's name
How did you hear about Arun Counselling Centre?
Availability*

MONDAY 9 -12MONDAY 1 - 5MONDAY 6 - 9TUESDAY 9 -12TUESDAY 1 - 5TUESDAY 6 - 9WEDNESDAY 9 -12WEDNESDAY 1 - 5WEDNESDAY 6 - 9THURSDAY 9 -12THURSDAY 1 - 5THURSDAY 6 - 9FRIDAY 9 -12FRIDAY 1 - 5FRIDAY 6-9SATURDAY 9 -1
ANY OTHER COMMENTS ON AVAILABILITY *
The more flexible you are the sooner we will be able to start your counselling
Any other comments or questions?
Please have a look at our website which explains the service and its location in further detail.

A COUNSELLOR will ring you to make an appointment for an assessment session once we have received this referral completed form. It may take a couple of weeks before that happens if we are very busy.

There is an ASSESSMENT FEE of £25 if in employment. If you are unable to meet this we may be able to reduce it. Any other amount would be the subject of discussion at the assessment session. All other ongoing fees can be discussed at your assessment.

Registered Charity No.293053 Accredited Association for Counselling and Psychotherapy
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