Self-Referral Form

This form is only for clients who are requesting to be considered for our low cost counselling services. Please ensure you complete the form as accurately as possible so we can move forward with your enquiry. It usually takes us 2 working days to consider your application and reply. Thank you for considering Ivy Light for your mental health support.
*Full Name

*Address
*Age

*Date Of Birth

*Email Address

*Telephone Number

Employer Name

Marital Status

*Emergency Contact Name

*Emergency Contact Phone

*Are you registered with a GP?


If YES please enter name and address of your GP?

*Do you have a disability?


If YES please list any diagnoses you have with details:

*Are you currently taking or receiving any medication?


If YES please list medication and details:

Details of any other relevant professionals you are seeing now:

Do you drink alcohol? If YES, how much do you consume in a week?

Do you use recreational drugs? If YES, do you plan on continuing to take them? Please provide details:

*Have you had counselling previously?


If YES when did you have counselling and with who?

Have you ever engaged in self-harming behaviours? If YES, please provide details, including the method and the date of the most recent occurrence:

Have you experienced suicidal thoughts? If YES, when was the most recent instance?

Have you ever made a suicide attempt? If YES, please provide details, including the method and the date of the attempt:

*What would you like to talk about during your sessions?
Any relevant family information?

*Please rate the severity of your problems or concerns on a scale of 1 to 10 with 10 being the most severe:


*Please choose the methods you are open to engaging with. You must select at least one option:


*What makes you eligible for our low-cost counselling service? Please provide a brief explanation of your current circumstances that make this service the most suitable option for you. This helps us ensure the low-cost service is reserved for those who need it most:
*Please select multiple days/times when you are available for counselling sessions. You must select at least one option:


Do you have any special requirements?

Is there any additional information you believe would be helpful for us to know?

*Verify: