Self-financing Referral for Counselling

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Unique ID

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Name(Required)

First Last

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.

Email(Required)

Enter Email Confirm Email

Phone Number(Required)

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Contact Preferences

How would you like your counsellor to contact you?

No preference

Phone call

Text

Home Address(Required)

Street Address Address Line 2 City Postcode Country

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Occupation

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Employer

GP Registration

Are you registered with a General Practitioner?

Yes

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

GP Medical Practice Name(Required)

GP Name (if known)

GP Practice Address(Required)

Street Address Address Line 2 City Postcode Country

Preference for Counselling delivery(Required)

What type of counselling would your prefer (dependant on availability)? Please tick all that apply.

No preference

In person

Telephone

Video call

Availability

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

Gender of counsellor(Required)

Do you have a preference for the gender of your counsellor?

No preference

Female

Male

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

Other – please specify

Have you used Rowan before?(Required)

Yes

Same Counsellor

If possible, would you like to see the same counsellor as last time?

Yes

Anything else?

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

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)

GDPR Consent Agreement(Required)

I agree to Rowan Consultancy keeping and processing my personal and sensitive data, in accordance with the current General Data Protection Regulations.

Yes

Costs

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Consent Information