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Please Note


There will be no charge made for cancellation of appointments when 24 hours notice is provided. However appointment cancellations with less than 24 hours notice and non-attendance of appointments will still be charged in full. 

Use this Referral Form to tell us about yourself or the person you are referring...
 

The referral form is designed to enable us to understand your problems, and allocate the best person to help you. Don't worry if you can't fill in all of it, just do what you can.

The information you provide on this form is sent securely to our company's email account which is received by our Team Co-ordinator.  We would advise not using this form if you are viewing this page on a public computer.

An alternative version, for downloading and completing offline, is available by clicking here.

Download it, print it out and fill it in, returning it to us by post or by hand delivery.

 

Is it OK to contact you at this address?
Is an interpreter required?
Is this referral made with your full agreement?
Are your Parents/Guardian aware of this referral?
Are you In Care/Care Leaver?
Have you seen a counsellor before?
Do you have a Doctor?
Are you taking any prescribed medication that we need to know about?
Are you receiving support from any other professional?
If ‘Yes’ please tick the ones which apply:
Do you have a learning difficulty or disability?

We invoice monthly and only charge for sessions completed although sessions cancelled with less than 24 hours’ notice will still be charged at the full rate.

Thank you for submitting. A member of the Time to Listen team will be in contact soon to discuss this referral with you.

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