West Mercia Women’s Aid
Referral Form

 West Mercia Women's Aid > Forms: Counselling Self-Referral Form

This service is open to past clients of WMWA who have already completed a programme of support with us.

Please complete all sections as fully as possible in order for this referral to be processed. Any incomplete information may result in a delay to the referral process.

Please note that some questions are for monitoring purposes only, and will not be used to determine eligibility for support.

Counselling Self-Referral Form

Please complete the form below

First Name*

Surname*

If we hold data for you in another name, please tell us it here:

Date of Birth*

Address*

Phone Number*

Email Address*

Preferred Method of Contact*

Are you having any counselling currently?*

Are you on any waiting lists for counselling?*

What kind of therapy is it for?

Who is the provider? (e.g. NHS, a charity, other provider)

How long do you expect to wait?

Have you had any other kind of talking therapy or counselling?*

If yes, please tell us when, how long for and how you helpful you found it:

Why would you like to have this counselling? What do you hope to get out of it?*

Select Location*

Please acknowledge* Please acknowledge* I understand that as part of this application, WMWA will access data already held on me to confirm that I have already been a client. I understand that I will need to attend a face-to-face assessment session before being accepted for counselling (likely to be Tuesday-Thursday). I understand that I cannot bring children or partners to the assessment or counselling sessions.

West Mercia Women’s AidReferral Form

Counselling Self-Referral Form

Please complete the form below

West Mercia Women’s Aid
Referral Form