Self Referral Form ( Confidential )

You can refer yourself by completing the form below. There is no need for a doctors referral. If you prefer to post the form please see the download at the bottom of the page, where you can print off , fill in and post to our Head Office as stated on the referral documentation.

Please be aware that About You UK is a Charity and receives no funding from any agencies. To access the services we suggest a donation of £25.00 per session (including assessment) to cover our operational costs (Private practice has a general cost of £45.00 or more). There will be an initial payment when the assessment is placed and then payments will be a week in advance of appointment.

If you have the ability to Gift Aid the charity will also benefit from this, receiving an additional 25% of your total donations.

'Donating through Gift Aid means charities and community amateur sports clubs (CASCs) can claim an extra 25p for every £1 you give. It will not cost you any extra.'

www.gov.uk

Referral Request – Confidential

Contact details are requested to help safeguard your right to confidentiality.

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Mobile Number: *

In-Person or Online Counselling? *

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