Counselling referral submission

We recognise that making contact with Zephyr’s can feel emotional, so this form is designed to be easy to complete. If you are finding it difficult, you can also ask someone to fill out the form on your behalf. Once completed and returned, we will aim to respond within 7 days.

The details you provide here will be held in absolute confidence by Zephyr’s and our Counselling Team, and you can find our Privacy Policy on our website. We work closely with a team of counsellors who may also read this form. We will never share your information with any other external parties, unless we have your prior permission to do so – for instance in order for you to access our other support services, or in the unlikely circumstances that we’re concerned about your safety.

Please note that all fields of this form must be completed in order for the referral to be processed. If there is information missing, we will contact you to request it, but this may extend your waiting time.

If you are looking for couples counselling (or completing this form on behalf of a couple) please note that we require a referral form submitting for each person individually.

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Contact details (of the person who would like support from Zephyr's) *

First

Last

Date of birth *

Phone number *

Email address *

Gender *

Ethnicity *

Address and postcode *

Name and address of GP *

Name and number of emergency contact *

can about or

To help us support you, please share as much as you can about what brings you/the referred person, to Zephyr's. *

To ensure we understand the context of your experience, and so we can match you with a suited counsellor, please try to include brief details about your loss(es), including: – who has died and your relationship to them (including a name, if applicable) – when they died, and at what age or gestation – the circumstances of your loss

Is there anything else you'd like us to know about you? *

e.g. your religion or faith, any medical or health related information, your accessibility requirements, or any other general background information it might be helpful for us to know 

Have you, or anyone in your family received counselling from Zephyr’s before? *

Please include their name and the name of their counsellor

Would you prefer to see a male or female counsellor? *

• I don’t mind
• Male
• Female

Please let us know your availability *

Please note our counsellors work within the hours of 9 – 5, Monday to Friday. Please highlight or include the times that work best for you. We cannot guarantee this but we will always do our best to accommodate.

And finally, how did you hear about our counselling service? *

Contact details of referee (Please only complete this if filling out on someone's behalf)

Please include your name, contact details, and relationship to the person being referred

Submit