• Adult Self-Referral

  • Who is this form for?

    This form is for adults (aged 18 and over) who are looking for support with stress, emotional difficulties, or managing everyday life, home, or education.

    Our goal is to get you the right help. If your needs are outside of what we can offer, we will work with you to connect you to an external service that can better support you.

  • Personal Details

  • Date of Birth*
     / /
    2 digit day, 2 digit month, 4 digit year
  • Permission to text or leave voicemail:*

  • Your Support Needs

  • We want to make sure our service is easy for you to access. Please let us know if any of the following apply to you:
  • Do you have a diagnosis of Autism?*
  • Do you have a diagnosis of a learning disability?*

  • Additional Information

  • Are you currently being seen by any other service?*

  • Agreement

  • By signing below, you give consent for us to contact you, as well as to store and process your personal data in accordance with our Data Protection Policy and Procedures.

  • Media & Photography Consent

  • We love celebrating your journey! We periodically take photos and short videos during programme activities to document progress, highlight achievements, and support fundraising. If you are happy to be included in this content, please let us know by selecting the options below:*

  • You can change or withdraw your consent at any time by contacting us in writing.

  • Should be Empty: