Counselling referral form

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Please note: all Headway Somerset services accessed via this referral form are paid for services. Our support groups remain free to attend (donations welcome), and you do not need a referral form to join them.

Please Note

Date*

Day

Month

Year

Patient First name*

Patient Last name*

Full Address including postcode*

Birthday

Day

Month

Year

Phone number*

Email of patient*

Communication/correspondence requirements*

Please provide a brief history of your brain injury, or that of the person you support, including any other medical conditions and your current situation*

Name & contact details of any other professional or specialist involved (Physio, Speech & Language, OT, Community Rehab Team, Social Worker*

Family Carer Details*

Name and contact details of person making the referral if not named above

Any other information you may wish to provide:

Please indicate the type of session you would prefer:*

Face to face sessions

Telephone sessions

Online sessions

If you have chosen face to face sessions, which location would you prefer? * *

Consent*

We offer counselling in blocks of 6 sessions. Each counselling session cost £40 so a block of 6 sessions costs £240. After your first session we will email you an invoice for 6 sessions. Once this invoice is paid, if you would like further sessions, you can have another block of 6 sessions at a cost of £240. For your information, if you have 12 sessions the total cost will be £480. Please tick the

This information is correct to the best of my knowledge

By submitting this form, you confirm that you have obtained consent from the named individual for their personal data to be stored and processed by Headway Somerset in accordance with our Privacy Policy.

This information will be securely stored and used to contact the designated individual. To help Headway Somerset support the named individual more effectively, we may need to share information with and receive information from other parties involved in their support.

All information will be kept strictly confidential and will only be accessible to staff on a need-to-know basis.

I agree to pay £40 per session of Headway Sussex Counselling.

Headway Somerset Registered Charity Number: 1097407

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