Brightfire CIC - Client Self-Referral Form 
Please complete this form for referral to one-to-one Psychotherapy/Art Psychotherapy/Brainspotting or Autism and ADHD Support, either via Zoom, or in-person in Hereford, UK.

We specialise in support for Autistic and/or ADHD clients. However this is not a requirement, and our services are available to all adults over the age of 16.

We will contact you following submission of this form to arrange a short free assessment session via Zoom to discuss your requirements in more detail, and for you to decide if our services are right for you.

In advance of sessions starting we will send you a client contract. An example of the client contract can be accessed here: 


In the event that we do not have current availability there is an option to be added to a waiting list.

All the information you provide will be held confidentially, not shared with other parties, and used just for the purpose of assessing your needs and for risk assessment purposes.

Sign in to Google to save your progress. Learn more
Client full name:
 *
Client's Date of Birth *
MM
/
DD
/
YYYY
Preferred pronoun:
Neurodivergence:
Are you diagnosed, or self-identify as follows:
Client's Post Code (Home Address) *
Client's Contact Telephone Number *
Client's Email Address *
Client's Preferred Method of Contact *
Are you making this referral for yourself or for somebody else? *
If you are making this referral for somebody else, please tell us your relationship to them and provide your contact details. *
If you are contacting us on behalf of someone else have they consented to you contacting us? *
Required
Please tell us briefly why you are seeking support *
What type of support would you like to access? *
Required
How would you prefer to access the service? *
Required

The session fee is £70 per hour.*

*I offer two slots per week at a half-price rate for clients experiencing financial hardship. If that is your position and you would like to apply for the concessionary rate of £35 please let me know. 

I am currently full for concessionary clients, but you can request to be added to our waiting list below.

Please select the standard or concessionary rate:

 *
Would you like to be added to our waiting list, if we are not able to offer you sessions at this time? *
Emergency contact details and relationship (parent, carer, friend, etc.) *
Are you currently being supported by a private therapist or NHS mental health service? *
GP Surgery where registered: *
Accessibility:
Do you have any accessibility needs you would like us to accommodate?
Physical Health: 
Do you have any serious physical health issues?
Mental Health History:
Have you ever been diagnosed, or feel you have experienced, the following?
Would you like us to inform you of other services we plan to provide in the future? Please select if you are interested in the following and would like us to inform you when available:
GDPR Consent (available via our website www.brightfirecic.com) *
Required
Permission to Contact *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms