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Community Counselling Online Referral Form

**We are unable to accept new referrals for Brief Counselling due to excess demand in Ryedale and lack of funding in Scarborough, Whitby and Filey. Please only use the form below to refer for Options  or MOJ Longer Term Counselling for Victims of Sexual Violence or Domestic Abuse.**

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








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