Make a Counselling Referral

MAKING A REFERRAL TO OUR SERVICES

By completing this referral form, you’re helping us to make contact with the client as safely and quickly as possible.  We’d appreciate it if you could include as much information as possible – this saves the client from being asked the same questions twice and helps us to understand more about their particular needs and circumstances. 

Referral Source
What kind of support are you seeking? (tick all that apply)
What kind of support are you seeking? (tick all that apply)
Preferred session format:
Are you currently at risk of harm from another person?
Are you currently at risk of harming yourself or others?

By submitting this form, I consent to Jonathan’s House CIC storing and sharing this information with relevant staff for the purpose of support and safeguarding, and I understand I can withdraw consent at any time.