Counselling self-referral form

Please fill out the form if you wish to self-refer to the Counselling service.

We will be in contact as soon as possible.

Indicates required field
Your personal details
Your contact details
Are you happy for us to contact you on this phone number?
Your first language
Is an interpreter required?
Your employment
Do you work for one of the partners of The University of Salford
Your referral
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?
What is this referral for?
Your history
Do you have any issues with anger or aggression?
Are you currently seeing a counsellor or mental health professional?
Have you ever seen a counsellor or mental health professional in the past?
Do you have a serious addiction to alcohol or drugs?
Have you ever been diagnosed with a psychiatric illness?
Your appointment
Your preferred time