Mid-Priced Therapy Self-Referral Form (Adults 18+)

First Name

Last Name

Date of Birth

Address

Postcode

Telephone Number

Email Address

Counsellor Preference

Counselling Preference

Preferred Days and Times

Presenting Concerns

Current Mental Health Support

Previous Counselling Experience

Goals for Therapy

Consent
I consent to this self-referral being made and to Protea Wellbeing contacting me regarding this referral.

Signature (please type your full name)

Date