Make A Referral Directly To Service Six

This form is for self-referrals (including assisted self-referrals, where someone helps you complete the form).

We will use the information you provide to assess your referral and offer the most appropriate support. Your information will be kept confidential and stored securely within Service Six.

Confidentiality is not absolute. We may share information without consent if we believe there is a serious risk of harm to you or others, to prevent or investigate serious crime, or where required by law or a court order. Our Confidentiality & Data Protection Policy is available on request.

We may use anonymised information for reporting. This will not identify you.

If you are currently receiving a high level of mental health care, or are already seeing another counsellor or psychological therapist, we may not be able to offer counselling/therapy. We may still be able to offer other support.

If you have any questions, contact Service Six on 01933 277520 or email referrals@servicesix.co.uk.

Please complete the form as fully as you can. If the form does not submit, check you have completed all required fields.