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Counselling Groups self-referral form

Please fill in the form below to register your interest in a group 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 * are required.

Date of birth * These groups are for ages 18 and over only.

Please explain the circumstances which bring you to access this type of support.

Enter a UK phone number (e.g. 0121 234 5678) or a number with an international call prefix.
Can we leave a message on your voicemail? *


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's surgery address

Your availability

We offer our counselling groups between 9am-5pm, Monday to Friday.