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Refer yourself for support

You don't need a GP or anyone else to refer you. Fill this in and our team will be in touch with next steps, including an honest idea of the current wait. There's no rush - share only what you're comfortable with.

Your details are encrypted in your browser before they are sent, and can only be read by our team. Fields marked *are required. If you're in immediate distress, please contact the Samaritans on 116 123 (free, 24/7) or call 999.

Who is this referral for?

For myself- you're on this one - You're an adult looking for counselling for yourself.
For a young person - You're a parent or carer referring a child or young person.
For us as a couple - You and your partner want to work on things together.
For our family - Your family wants support together rather than one at a time.
Creative therapy for a child - A child would be better helped through play and creativity than by talking alone.

About you

First name *

Last name *

Title (optional)

Date of birth (optional)

Relationship status (optional)

Number of dependants (optional)

Is someone else making this referral?

Only if a school, GP, support worker or someone else is filling this in on their behalf. Leave it empty if you're referring yourself.

Their name (optional)

Organisation (optional)

Their phone (optional)

Their email (optional)

How can we reach you?

Email address *

Mobile number (optional)

Home phone (optional)

Postcode (optional)

Address (optional)

It's OK to leave a voicemail or message if we call.

Your GP

Optional - it can help us support you, but you don't have to share it.

GP name or practice (optional)

GP phone (optional)

GP address (optional)

GP postcode (optional)

What brings you here?

In your own words * Share as much or as little as you're comfortable with.

A little about your circumstances

All optional. Only tick what applies - it helps us support you well and match you with the right person.

I have a disability or access needs

I'm currently experiencing mental-health difficulties

I've had a recent hospital admission

I'm taking medication

There are current legal proceedings involving me

I've had counselling or therapy before

Getting to us, and being comfortable when you do

All optional. It helps us pick the right room and make the appointment workable.

I can manage stairsI'm deaf or hard of hearingI'm blind or have a sight impairmentI have another access need

Anything that would help us (optional)

Language (optional)

Allergies (optional)

Your preferences

All optional - we'll do our best to match them.

How would you like to meet? (optional)

Counsellor preference (optional)

When are you usually free? (optional - tick any that suit)

Equal-opportunities monitoring

Entirely optional and never used to make decisions - it only helps us check we're reaching everyone fairly. Skip any you'd rather not answer.

Gender (optional)

Sexual orientation (optional)

Ethnicity (optional)

If you chose another ethnic group, please describe it (optional)

I consent to Empathy Northwest CIC using the information I provide here, including anything I share about my health or reasons for seeking support, to contact me and arrange therapeutic support. I understand it is kept confidential, that I can withdraw my consent at any time, and that it is handled as set out in the Privacy Policy. *

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