CONTACT US
Please contact us at Aire, Wharfe and Craven Counselling using the form below for Appointments and General Enquiries.

CAVENDISH BUSINESS CENTRE, 11-17 CAVENDISH STREET, KEIGHLEY, BD21 3RB
01535 288335 OR 01535 288332
info@awc-counselling.co.uk
www.awc-counselling.co.uk/

Referral Form

How did you hear about us? (required)

Your Name (required)

Date of birth e.g. dd/mm/yyyy (required)

Phone number (required)

Address

Postcode (required)

Your Email (required)

GP Surgery

Gender

Disability (please select all that apply)

NoneBehaviour & EmotionalHearingManual DexterityMemory or ability to concentrate, learn or understanding (Learning Disability)Motor & Gross MotorPerception of Physical DangerPersonal, self care and continenceProgressive conditions and physical health (such as cancer, HIV, MS, Fits)SightSpeechAutism and other Neurological conditionsOther

Ethnicity

Preferred language

Sexual Orientation

Have you been convicted of sexual offences?

Primary reasons for referral?

Please tell us in a little more details about the reasons for accessing counselling. Do you want to talk about your current situation, or maybe something from the past that is affecting how you feel now? How does it affect you?

Have you been diagnosed with a mental health condition?

If yes, please tell us a little more about your condition?

Please tell us your diagnosis, are you taking medication? Do you have a mental health professional supporting you? Please provide their details:

Would you prefer in person counselling or counselling remotely (select from drop down box)

When would you be available for counselling (*tick all your availability)

Monday morningsMonday afternoonsMonday eveningsTuesday morningsTuesday afternoonsTuesday eveningsWednesday morningWednesday afternoonWednesday eveningThursday morningThursday afternoonThursday eveningFriday morningFriday afternoonFriday eveningSaturday morning

Please prove you are human by selecting the Car.