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Refer your family

For families who want to work on things together. We ask about each person separately, because everyone brings their own history - add as many people as are part of the work.

Looking for something else? for myself, for a young person, for us as a couple, creative therapy for a child.

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.

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)

Everyone else joining

We ask about each person separately, because everyone has their own history and their own health. Leave a block empty if there's nobody there.

About another family member 1

First name

Last name

Title (optional)

Date of birth (optional)

Relationship to you (optional)

Relationship status (optional)

Number of dependants (optional)

Postcode (optional)

Address (optional, if different from yours)

Mobile (optional)

Home phone (optional)

Email (optional)

Their GP (optional)

GP address (optional)

GP postcode (optional)

GP phone (optional)

It's OK to leave them a voicemail or message

Allergies (optional)

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

They have a disability or access needs

They're currently experiencing mental-health difficulties

They've had a recent hospital admission

They're taking medication

There are current legal proceedings involving them

They've had counselling before

Gender (optional)

Sexual orientation (optional)

Ethnicity (optional)

If another ethnic group, please describe (optional)

About another family member 2

First name

Last name

Title (optional)

Date of birth (optional)

Relationship to you (optional)

Relationship status (optional)

Number of dependants (optional)

Postcode (optional)

Address (optional, if different from yours)

Mobile (optional)

Home phone (optional)

Email (optional)

Their GP (optional)

GP address (optional)

GP postcode (optional)

GP phone (optional)

It's OK to leave them a voicemail or message

Allergies (optional)

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

They have a disability or access needs

They're currently experiencing mental-health difficulties

They've had a recent hospital admission

They're taking medication

There are current legal proceedings involving them

They've had counselling before

Gender (optional)

Sexual orientation (optional)

Ethnicity (optional)

If another ethnic group, please describe (optional)

About another family member 3

First name

Last name

Title (optional)

Date of birth (optional)

Relationship to you (optional)

Relationship status (optional)

Number of dependants (optional)

Postcode (optional)

Address (optional, if different from yours)

Mobile (optional)

Home phone (optional)

Email (optional)

Their GP (optional)

GP address (optional)

GP postcode (optional)

GP phone (optional)

It's OK to leave them a voicemail or message

Allergies (optional)

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

They have a disability or access needs

They're currently experiencing mental-health difficulties

They've had a recent hospital admission

They're taking medication

There are current legal proceedings involving them

They've had counselling before

Gender (optional)

Sexual orientation (optional)

Ethnicity (optional)

If another ethnic group, please describe (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 - times that suit everyone coming)

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 on this form, including anything about health or reasons for seeking support, to contact us and arrange therapeutic support. I understand it is kept confidential, that consent can be withdrawn at any time, and that it is handled as set out in the Privacy Policy. *Everyone I have named here knows about this referral and is happy for me to give their details, including anything I have said about their health. I understand they can contact you themselves about their own information at any time. *

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