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Counselling and Wellbeing Referral
Please note that the information you provide on this referral will be sent directly to Leanne Duthie (Wellbeing Counsellor) and will not be shared with anyone else.  Counselling is a confidential space. The information you provide will not be shared with anyone else - unless I feel you are at risk or pose a risk to others. In this case I would be duty bound to share this information but would always seek to gain your permission.  
     
Email *
Full Name: *
Date of Birth: *
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Gender *
Contact No: *
Email address: *
Preferred method of contact: *
Name of Assessor/Caseworker: *
Please could you tell me what you are struggling with:   *
If you would like to provide further details regarding your issue(s) please use the space below:  
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