Emergency mental health session referral form

Please fill in the form below to request an emergency mental health session with one of our trained counsellors.

If you have any questions or have difficulty completing this form, please call our Helpline on 0303 123 9999 or email [email protected].

Fields marked with an asterisk (*) must be filled in.

First name * required

Last name * required

Phone number * required

Can we leave a message on your phone? * required

Yes

Email address * required

Confirm email address * required

Address

Postcode * required

Address 1 * required

Address 2

Town/City * required

County

Your GP's contact details

By providing us with your GP's details, you give us permission to contact them in the event of an emergency.

GP/Surgery name:

Phone number:

Address:

Your availability

We offer one-hour sessions between 9am-5pm, Monday to Friday.

Please let us know when you're available: * required

To check you're not a robot, please enter the answer to the following equation: 3+2 = * required

We are committed to protecting your privacy and want to assure you that your personal information is safe with us. For more information, please read our privacy policy.

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