Counselling Service Self-Referral Form

It takes courage to reach out and ask for help. So firstly, before you fill in the rest of this form, I want to acknowledge that first step towards doing something proactive to support your wellbeing. Well done on taking that step, a step I know is not always easy to take. By completing this form, my aim is that you can access the service as easily as possible and that we find the right therapist for you. Your mind might be busy with questions about how the process will unfold but that’s ok, when you have completed this form, I will take it from there and be in touch with you shortly.

Warm Regards, 


Counselling Service Self-Referral

(e.g. require wheelchair access, interpreter etc.)
(You may select more than one option if it applies)
(Please be aware you do not have to be a member to use our Counselling Service)
(For ethical reasons, clients who are related are not generally seen by the same counsellor so it is important to know this information)
(e.g. addiction services, mental health services)
(for example: exercise, meditation, healthy sleeping habits, eating well)

The counselling service is part of many different services the IKA offer to you, your family or carers. Please click to see other services available that may help to support you at this time.