Referral Form

Referral Form
We are Progress Cymru Counselling, Wales’ only charity dedicated to supporting LGBTQ+ people by providing affordable mental health services to those who need them.

We ensure that LGBTQ+ people across Wales can access high-quality counselling and therapeutic support without facing barriers because of cost, background or personal circumstances. We believe that mental health support should be inclusive, affirming and accessible to all, and we are committed to creating a service where people feel safe, respected and understood.

As an LGBTQ+ counselling service, our funding is focused on supporting LGBTQ+ people. We also include parents, partners and children of LGBTQ+ people where this falls within our funding criteria. We recognise that the people around LGBTQ+ individuals may also need support, and that families, relationships and support networks can play a vital role in mental health and wellbeing.

Reason for accessing counselling:
What is hoped to be achieved through counselling:
Before your first session, one of our counsellors will make contact with you, how would you prefer they contact you? Our working hours are Monday to Friday, 9am to 4:30pm.
Contact Preference
When would be best to contact you?
We offer a sliding scale donation model for our counselling sessions, this mean that you only pay what you can afford, please let us know how much is affordable for you to donate per session:
Donation per session:

Other
Our sliding scale model ranges for free-of-charge to £35 per session, any more that you give shall be used to pay it forward, as a donation for others who may not be able to afford counselling.

Referral Form
GP Details
Name:
Number:
Address:
Is the client on any medication, If yes, please specify?
Does the client have any previous experience of counselling?
Is the Client receiving any other type of therapy at the moment, if yes, please specify: (Psychiatrist, CAMHS, CMHT, substance misuse services, family therapy etc)?
Type of Counselling required:
Type of Counselling required:
Client Age Group:
INTERNAL USE ONLY
Was the referral appropriate, if not, what is the reason for this?
Allocated to:
Date allocated:
Date of first sessions:
Donate Amount:
Should be Empty: