Adult Counselling Referral Form - Face-to-face

For clients aged 6-17 years old, please complete the Child Counselling Referral Form on the previous page. Face-to-face appointments are charged at £55 per session.

Full name

Sex (as registered at birth)

Pronouns

Gender

Phone

Your Postcode

Reason for seeking therapy?

Have you ever been assessed or formally diagnosed with:

Additional information:

Please select if:

You are or have in the last 2 years experienced suicidal ideations or feelings of wanting to self-harm

You have previously attempted suicide or self-harmed (within the last 2 years)

Which day(s) are you available?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Which time(s) are you available?

Morning (9am-12pm)

Early afternoon (12pm-3pm)

Late afternoon (3pm-6pm)

Evening (6pm-9pm)

Please confirm if you have a preference on the gender of your counsellor

Male

Female

No preference

Where did you hear about us?

If other, please detail below

I am happy to receive information about mental health (support, news and resources) from TCS in the future

Before you submit your referral, please tick here to consent to storage and processing of your data

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