Progeny Counselling - Trauma Therapy for Teens and Young Adults

Progeny - Therapy Self Referral

First Name

Last name

Age

Phone

Why are you seeking therapy and how can we help?

Have you ever received mental health support from any of the following services? (GP, Counsellor or Therapist, CAMHS, Community Mental Health, Community Addictions, Crisis Team, Psychiatrist, Psychologist, Other - please describe.

Have you had any formal diagnosis (i.e. OCD, ASD, ADHD etc) or any form of disability?

Any current safety concerns (self-harm/suicidal thoughts)

Preferred Session Format: face-to-face in Ballymena or Online via Zoom?

On which days and at what time of day are you regularly available for sessions?

I have reviewed the suggested donations and can pay:

£60/Session (client is full time employed)

£35/Session (client is part time employed or on benefits)

Exceptional Circumstances (see below)

If you're experiencing exceptional circumstances, we may be able to offer a further reduced rate. If this applies to you, please share a little about your situation so we can consider your request.

I wish to submit this referral and consent to my personal data being stored and processed. I also consent to being contacted by phone or email regarding my referral.

Therapy isn't a 'crisis' service. If you are in need of urgent mental health care, please reach out to your GP, Crisis Team or Casualty Department.

PROFESSIONAL EXCELLENCE CHRISTIAN HEART

Progeny - Therapy Self Referral

PROFESSIONAL EXCELLENCE
CHRISTIAN HEART