Referrals

If possible, please fill in the short referral form below in order for us to confidentially gather some more information about your circumstances. We aim to get back to you within 24-48 hours after receiving this. Or, if you would prefer, please call the number and we can take your details over the phone or call you back. 

 

Referral for adults

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

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.