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School of Health and Society

Self-referral form

Welcome to the University of Salford Counselling and Psychotherapy Centre Self-Referral form. Please complete the form below, filling in all mandatory fields indicated by an asterisk. If you have any questions please do not hesitate to contact us by email, at:

Date of birth *
Is an interpreter required? *
Are you happy for us to contact you on this phone number?
Do you work for one of the partners of The University of Salford: *
Is this referral in relation to support for carers / are you a carer of someone with Dementia? *
Have you previously accessed the Counselling Centre service or attended an assessment here? *
Is this referral for: *
Do you have any issues with anger or aggression?
Are you currently seeing a counsellor or mental health professional?
Do you have a serious addiction to alcohol or drugs
Have you ever been diagnosed with a psychiatric illness?
Have you ever seen a counsellor or mental health professional in the past?
I accept terms and conditions *
Please indicate which time slots work best for you: We will try to offer appointments at times that are convenient for you wherever possible.