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Community Counselling Online Referral Form

Please use the form below to refer for Options, Longer Term Counselling for Victims of Sexual Violence or Domestic Abuse and for our Pilot Brief Counselling Service in Ryedale.

Please complete as much of the information required as you can for your referral.  We will get in touch with you as soon as possible. We are continuing to operate as a hybrid service and offer telephone, online and limited face-to-face counselling. 

 

Personal Information
Address
Phone and Email
Details
Referrer Details
Medical Details
Appointment Preferences