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Adult Referral Form

Referral Form

We are not a crisis service. Go to the Crisis Support page for sources of help, including NHS 111.

Please complete the form below if you would like to access our brief counselling services in Ryedale or

our chargeable Options service.

The waiting lists for our Scarborough and Ryedale brief counselling services are currently closed.

Referrals to these services will be returned.

Fields marked with* must be completed.

Crisis Support

Self Referral *

Yes

Name of person (if not self referral)

Referral agency and contact details (if not self referral)

First Name

Last Name

Phone

Street Address 1

Street Address 2

Town

Postcode

Gender

Date of Birth

Presenting Issue (briefly explain the reason for counselling)

Have you attended counselling or accessed a mental health service in the last 12 months?

GP Name

Appointment Preferences

Face to Face in Malton

Telephone

Online

Can we leave a message on your phone

Yes

Access Issues (wheel chair, communication)

Have you received any drug treatment for a mental health condition in the last 12 months?

Name of GP Surgery

Please indicate which service you would like to access

How did you hear about us? * Required

Other NHS service

Other organisation eg. MIND

Family or Friend

TikTok

Instagram

Facebook

Internet Search

Other

Thank you for your referral.

Due to demand we will be in touch within 6 weeks to arrange an appointment.

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Community Counselling (North Yorkshire) Limited

Stanley Harrison House, Norton Road, Malton, North Yorkshire YO17 9RD

(t) 01653 690 124 (e) info@community-counselling.org.uk

Charity number 1151230; Company number 8399767

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