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Get In Touch

Adult Counselling Referral

Please fill out the following form.

All information will be treated as confidential.

Only use this form for adult self referrals

First name*

Last name*

Date of birth*

Day

Month

Year

Address*

Email*

Phone*

Which Health Trust are you under?*

Northern Trust

Belfast trust

South Eastern Trust

Western Trust

Southern Trust

Please provide us with the name of your GP practice & address (this is for gathering service statistics)*

Tell us about what is going on for you at the minute / in the past that you feel counselling will help you with.*

What would you like to get out of counselling? What difference would it make to your life?*

Do you have any diagnosed or undiagnosed mental health conditions?*

Diagnosed

Undiagnosed

Please provide as much information as possible (MH)

Do you have any physical health conditions?*

Yes

Please provide as much information as possible (PH)

Are there other area(s) our service can support you with?*

Food Larder

School Uniform Scheme

Isolation & Loneliness

Digital Skills

Advice & Support

Not this time

Other

Please tell us how you heard about our service*

A member of our team will ring you to complete a referral form and an assessment will be required to ensure suitability for our service.

We are running an extremely busy service and aim to get in touch with you as soon as possible. I understand this is not a crisis service and in an emergency i will contact one of the services listed below for immediate support.

Permission to contact

A Safe Space to be Me

info@asafespacetobeme.co.uk

028 9620 8284

Safeguarding Policy

Equal Opportunities Policy

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