Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred method of communication? * Please note, most of our admin is done via email but our counsellor will endeavour to contact you in the way you prefer once you've been reffered *

Phone

Email

Please select which form of counselling you would prefer: *

Please select all that apply.

Online counselling

Face-to-face counselling

If you've selected face-to-face counselling above, please select which centre(s) you would like to be seen in: *

Please select all that apply.

Cardiff

Pontypridd

Afan Valley

Would you be happy to complete an online assessment? *

This can be completed over the phone if you are unable to complete an online assessment.

Yes

No

Is it OK for us to: *

Please select all that apply.

Leave a voicemail?

Send you a text?

Send you an email?

Please tick any issues below that you would like to bring to counselling: *

Relationship problems

Bullying

Grief

Self-knowledge

Feeling suicidal

Anxiety

Depression

Past trauma

Anger

Eating disorders

Gender

Sexuality

Identity

Self harm

Substance misuse

Addiction

Confusion

Other

T&Cs *

By ticking this box, you are confirming that you accept and understand that Concern Cymru will keep the information you have given on this referral form until six months after the counselling I receive has ended, or for six months from the date I decide that I no longer want to receive counselling from Concern Cymru. 

I accept