This page is for clients who have already been in contact and are ready to confirm their session.

Please only proceed if you have been invited to do so.

Making a referral is a meaningful step towards support and change. We recognise the courage it can take to reach this point, and we’re here to hold that with care. Once your referral is received, we will gently guide you through the next steps, ensuring a safe and supportive experience throughout.

Supporting Each Step

Personal Assessment

Client Details

First Name

Last Name

Date of Birth required

Phone Number

safe contact details

Street Address

Street Address line 2

City

County

Postcode

*We will not send anything to your address without prior confirmation

Emergency contact name/Relationship

Emergency Contact Phone

Referral Details

How did you hear about Forward2Freedom

Have you had Counselling before?

Presenting Issues

What brings you to counselling at this time?

When did these difficulties begin?

What impact are these having on your daily life?

Personal Health Information

Name of GP and Surgery inc Address

GP Phone

Are you currently receiving any medical or psychological treatment?

Are you currently taking any medication?

Have you ever been diagnosed with a mental health condition?

Any medical conditions we need to be aware of?

Risk Assessment (confidential)

Have you ever had thoughts of harming yourself or others?

Do you feel safe in your current living situation?

Do you feel safe in your relationship?

If you feel at immediate risk please call 999

Lifestyle & Support

Who or what supports you at the moment?

Do you have any spiritual, cultural, or personal beliefs that are important to you and should be considered in therapy?

Current Occupation / Daily Routine:

Counselling Goals

What would you like to gain or change through counselling?

Practical Details

Preferred Method:

Online

Telephone

Preferred time:

Morning 9am-12noon

Afternoon 12noon-5pm

Please select as many options as you can to help us meet your needs

Confidentiality & Data Protection

All information shared in counselling is kept confidential, except where there may be a risk of serious harm to yourself or others, or where legally required. Your data is stored securely in line with GDPR regulations.

Client Consent

By sending this form, I confirm that the information provided is accurate to the best of my knowledge and understand the counselling process, confidentiality boundaries, and data protection policy.

Thanks for your referral!

Supporting each step