Corporate Self-Referral for Counselling – Rowan Consultancy Forms

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This field is for validation purposes and should be left unchanged.

Unique ID

User logged in. This form is now in telephone referral mode.

Date of Birth(Required)

Please note that you need to be over 18 years old to use this form. Select the year of birth first.

Phone Number(Required)

Occupation(Required)

Employer(Required)

Please update your counsellor when you have registered with a GP Practice

GP Medical Practice Name(Required)

GP Name (if known)

Availability

Do you have any specific availability for sessions or times that you can’t do?

Anything else?

Is there anything else you would like us to consider when finding you a counsellor?

How did you hear about Rowan's service?(Required)

Other – please specify

Consent Information

Data protection legislation requires that we obtain your explicit consent to keep records. Records include: your contact details, information such as practitioner notes, and assessment information. We keep all records in accordance with current General Data Protection Regulations.

Read Rowan’s Privacy Policy here (Opens in new window)