Affordable Therapy Self-Referral Form (Adults 18+)

First Name

Last Name

Date of Birth

Age (18+)

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