Little Miracles Counselling for Families.
Thank you for providing us with this information. Due to our Data protection, your data is being saved on our secure system. We will not pass on your data to another organisations unless there is a safeguarding concern, but from time to time we may contact you to discuss being a case study for Little Miracles, this will not be done without your consent. If you do not consent to this please do not fill in this form and contact us on
For counselling and support services please complete the self referral form below with as much detail as possible. If you feel unable to complete the form or wish to speak to someone urgently please ring 01733 262226, email firstname.lastname@example.org alternatively please come into the centre. Any information provided will be strictly confidential.
Name of Person filling in form
Do you have a disabled child?
Are you a member of Little miracles?
Name, age and DOB of person requiring counselling
School / college / university if applicable
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