Self Referral Form              ( Confidential )

You can Refer yourself by completing the form below, if you require to post the form please see the download at the bottom of the page of whitch you can print off and fill in and post to our Head Office as stated on the referral documentation. 


Please be aware that the Philippi Trust is a Charity and receives no funding from any agencies. To access the Services we request a minimum donation of £15.00 per session to cover our operating costs.

Background Information – Confidential

Please do not be anxious, if you have difficulties at all in completing this form, please telephone the office and we will offer all the help we can.  Contact details are requested to help safeguard your right to confidentiality.  Please tick the appropriate boxes – if none are ticked we will not be able to contact you to offer you your appointment.

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Self Referral Form

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Self Referral Form
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Assessment Doc 2018.docx
Microsoft Word document [1.1 MB]
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