The Edinburgh Counselling Service Self-Referral Form
This form is for adults (18+) seeking to access concession counselling. Sessions are for weekly face to face sessions, and are on a sliding scale from £30-£55. 
We currently offer concession counselling on Mondays (9am-4pm), Tuesdays (12-3pm), Wednesdays (12-3pm), and Fridays (11-3pm).
These sessions are provided by our counselling and psychotherapy trainees.
If you would like to self-refer, please fill out the form below. 
The information provided will be kept confidential and will only be accessed by the therapy team on a strict need to know basis. 
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Name *
Email Address *
Telephone Number *
Date of Birth *
Pronouns (she, he, they)  *
GP Practice  *
Emergency Contact
Please provide their name, telephone number and relation to you (friend, family, flatmate etc.)
 *
Our reduced fee counselling spaces operate on a sliding scale from £30-55. We ask clients to only pay what feels affordable to them within this amount. Please indicate what amount you wish to pay:
 *
Please kindly let us know your availability. Please note, the more detailed your availability, the more likely we are able to allocate you a space.
*
Required
Are you taking any prescribed medication that we need to know about? 
If yes, please specify:
*
Do you have any medical conditions or allergies that we need to know about? 
If yes, please specify:
*

Are you receiving support from any other professional (GP, Psychologist, Psychiatrist etc.)?     

If ‘Yes’ please provide brief details:

 *

Please tell us briefly what issues or feelings are worrying you, or what you would like to explore in sessions. This helps us to match you to an appropriate therapist.

*

If you prefer, please feel welcome to tick the boxes you feel apply to you.

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Required
How did you hear about us? *


Terms and Conditions

By filling in this form and attending an initial consultation and/or counselling with us, you agree to our terms and conditions (full details can be found on our website here). You understand that our low cost counselling sessions are provided by a Counselling Psychology Trainee or a Trainee Counsellor/ Psychotherapist. All trainees are closely supervised by their clinical supervisor and their training institution to ensure a high quality of counselling provision.

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