restoring wellbeing through contact

Referral form


To make a referral, please fill in the online form below or download the General Referral Form, which can either be posted or faxed to our Head Office.

Please fill out the following form(s) and click send. Only designated Contact staff will have access to this information. View our privacy policy for more information. 

Please complete both referrer details and client details below if you are referring someone on their behalf. If you are referring yourself, only complete client details section.


Referrer Details


Is the person aware that this referral is being made?

Contact name

Email Address

Contact number

Address details

Please continue to client details section to
complete the referral.

Client Details

First name

Last name

Date of birth

Male Female

Reason for referral

EG. Directly or indirectly affected by depression, bulling, suicide, family conflict, drugs or alcohol problems, school problems, sexual identity, other...

Preferred contact number

If you would like to hear from one of our counsellors please fill in a number they can reach you on.

What time is most suitable to hear from a counsellor

We aim to call you within 48 hours of receiving your referral.

Would you like to receive information in the post?
Yes No

Address details

Where did you hear about our service?

Have parents been informed of referral?
Yes No

Special needs / any other relevant information

GP information

send submit