Professional / Agencies Online Referral Form

Please complete this form to refer someone to our service. Review our privacy policy here.

About The Referrer

About The Person You are Referring


Only supply contact information that is safe for us to use. Please supply at least one contact method

More Information

Support Needs

Please note that for our Counselling Services, people need to be at least 12 months free from using substances or alcohol abuse and at least 6 months since any previous attempts on their own life or incidents of self harm. This will enable them to get the most from their therapy. However our ISVA services are able to support people within those categories.

In this next section we will ask you about the reasons they are seeking support on behalf of the client.


Please tell us about the clients safety: