Referrals - suspended until Sept 2019

PLEASE NOTE: Due to high demand, online referrals are currently suspended for a period of 3 months while we manage the waiting list. Please do not fill in the online referral during this time. However, if your query is urgent, please phone to speak to a member of staff or leave a message.

 

Referral for adults - CURRENTLY SUSPENDED

Name *
Name
Address
Address
Is it OK for us to:
Please indicate the best time slots for you:
Can you use the stairs?
There is a steep set of stairs in the Cardiff office
Gender
Which centre
Please specify your first choice of centre
T&Cs *
By ticking this box, you are confirming that you accept and understand that Cardiff Concern will keep the information you have given on this referral form until six months after the counselling I receive has ended, or for six months from the date I decide that I no longer want to receive counselling from Cardiff Concern. 
 

Referral for children - CURRENTLY SUSPENDED

Child's name *
Child's name
Child's gender
Parent/Guardian name
Parent/Guardian name
Address
Address
Is it OK for us to:
Please indicate the best time slots for you:
Can you use the stairs?
Can you use the stairs?
If so, please specify
T&Cs *
By ticking this box, you are confirming that you accept and understand that Cardiff Concern will keep the information you have given on this referral form until six months after the counselling I receive has ended, or for six months from the date I decide that I no longer want to receive counselling from Cardiff Concern.