Adult Counselling Referral form

Our Adult Counselling Service is delivered by volunteers and is not a free service. Individuals are expected to make an affordable contribution towards the cost of their counselling. Please see our Guidance for more information.

Please note: this service is not a crisis service and will not be suitable you are at immediate or imminent risk to yourself or others.

 

For those who feel that they are in distress, for example if you feel at risk of harming yourself or others then we would urge you to contact any of the following organisations who are able to offer support:

  • NHS (non-emergency) 111 (24hrs)
  • Samaritans (Helpline)116 123 (24hrs)

Alternatively, we would request that you contact your GP. Or if in crisis, attend your local A&E department. (You may wish to call an ambulance on 999)

 

By completing this form you agree to Gaddum keeping this information stored on a secure electronic case recording system in accordance with GDPR. If you want to find more about how we use people’s information, you can access our privacy policy here: Privacy Policy - Gaddum .

 
1 Start 2 Complete
Client name
Referrer Details (Please answer these questions if you are completing this referral on behalf of someone you're supporting)
Details of person being referred
Client Demographics Questions
Accessibility Information (e.g. interpreter, learning difficulties etc.)
GP information
Appointment preference (Please note, we operate between 9:00am and 16:30pm.)
Please be aware that sessions will not be in-person, face to face sessions.

Please be aware that cannot proceed with this referral without consent.