The Hike With Mike Foundation - Referral Form

Thank you for reaching out. Please take a moment to read this section and fill out the form. Someone from our team will reach out to you as soon as possible (within 24 hours) to discuss how we can support you. If you don't already have a therapist in mind, please do visit www.counselling-directory.org.uk while you await our reply. Please regularly check your email Inbox, Spam or Junk folders for a response from us.

Please be assured, the information you give us on this form remains confidential, and will only be used for the purpose of delivering counselling services to you. 

Important Information: 
*If you are filling out this form on behalf of someone else, please enter the details of the person requiring the referral.

If you need to contact us for general enquiries not relating to receiving counselling, please do so on enquiries@thehikewithmikefoundation.com 
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Name *
Are you over 18? *
Contact number  *
Email address *
Please tell us a little about the reason you're reaching out to us *
First part of your postcode (e.g NG3)  *
this will help us to source appropriate help in your area
Preferred method of therapy  *
Do you have a therapist in mind already?  *
You can find one here www.counselling-directory.org.uk 
Please add any additional information here
Consent *
I give consent for The Hike With Mike Foundation to provide counselling services to me. I understand that my personal information will be used for the purpose of arranging and delivering these services, including providing an agreed counsellor with my contact details. I understand I can request a copy of Privacy Policy.
If you are filling out this form on behalf of someone else 
please add your name and telephone number here
How did you hear about us? *
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