Self Referral Form ( Confidential )

You can Refer yourself by completing the form below, if you require to post the form please see the download at the bottom of the page of whitch you can print off and fill in and post to our Head Office as stated on the referral documentation.

Please be aware that About You UK is a Charity and receives no funding from any agencies. To access the Services we request a minimum donation of £25.00 per session to cover our operating costs. There will be an initial payment when the assessment is placed and then payments will be a week in advance of appointment.

If you have the ability to Gift Aid the trust will also benifit from this recieving an additional 25% of your total donations.

'Donating through Gift Aid means charities and community amateur sports clubs (CASCs) can claim an extra 25p for every £1 you give. It will not cost you any extra.'

www.gov.uk

Background Information – Confidential

Please do not be anxious, if you have difficulties at all in completing this form, please telephone the office and we will offer all the help we can. Contact details are requested to help safeguard your right to confidentiality. Please tick the appropriate boxes – if none are ticked we will not be able to contact you to offer you your appointment.

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Self Referral Form

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Name: *

Date of Birth: *

Full Address incuding Postcode *

E-mail address: *

Telephone/fax: *

Mobile Number: *

Occupation: *

Family Details (Single/Married/Divorced/children etc.) *

In-Person or Online Counselling? *

May we contact you by telephone?

May we contact you by telephone and leave a message?

May we contact you by letter?

May we contact you by email?

Have you been Adopted or in Care

Name of Doctor & Surgery Address *

Have you suffered from any form of psychiatric illness? If Yes give Detail: *

Are you taking any medication? If Yes give Detail: *

Any other information you think we ought to be aware of? If Yes give Detail: *

Have you received previous counselling? If Yes give Detail *

How would you define your problem? *

Captcha (spam protection code): *

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I herby agree that my data entered in the contact form will be stored electronically, and will be processed and used for the purpose of establishing contact. I am aware that I can revoke my consent at any time.

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