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Referral Form

A Unique Counselling Hub in Lincoln
Providing Services to People in Lincolnshire and Beyond.

Contact Us

Please fully complete all sections to help us deal with your request appropriately. Fields marked * are mandatory:

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Please provide emergency contact details or, if you are under 18, contact details for your parent/guardian: *
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Are you registered with a GP?
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Do you have a disability?
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Are you currently receiving/taking any medication?
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Have you had counselling previously?
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Is there any other relevant information you would like your counsellor to know? e.g., family, cultural, religious, etc.
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Please rate the severity of your problems or concerns on a scale of 1 to 10, with 10 being the most severe
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What method of communication would you prefer for your counselling sessions? *
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Will you be self-funding your sessions? *
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Do you have funding arranged? *
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If Yes, please give details
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Do you wish to discuss funding options? *
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What would you like to gain from your counselling sessions? *
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If 'other', please state.
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How do you want your counsellor to work with you? *
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Availability *
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Ethnicity
When applying for funding to continue our work, we are asked to supply data about who uses our service to support our application. We would be grateful if you could provide the following information. Any monitoring information shared is done so anonymously; however, if you do not wish to provide this information, please select “Prefer not to say”:
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Sexual Orientation:
(Please enter here or check the box if you prefer not to say)
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Completed By: *
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All personal data is processed in accordance with the right of Data Protection Act 1998 and The General Data Protection Regulation (GDPR) 2018. GDPR is a regulation in EU law on data protection and privacy for all individuals within the European Union and the European Economic Area. The GDPR aims primarily to give control to citizens and residents over their personal data. Please find our privacy statement on our website and ask to see our full privacy policy.