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Home / Adult Counselling Services Referral Form

We are currently experiencing an intermittent issue with our online referral form, which we are trying to resolve.  If you experience any technical difficulties with submitting the form,  please contact: [email protected] or call 01494 463364. Alternatively, you can download, complete and return a referral form by clicking here.

We apologise for any inconvenience.

Adult Counselling Services Self-Referral Form

Please use this form to self-refer to our face-to-face or online counselling services for adults.
Is it OK to leave a message from Buckinghamshire Mind on this number?
Is it OK to leave a message from Buckinghamshire Mind on this number?(Required)
Is it OK to leave a message from Buckinghamshire Mind on this number?
Please select which service/fee is most suited to your needs(Required)
Once we receive your referral, a member of staff will contact you via email with further information. Once we receive all the required documents, you will be placed on our waiting list for an initial assessment until we have an available time slot to offer you. However, if you have chosen our Rapid Access service, we will offer you an initial assessment within a week.
What is your preferred time for an appointment?(Required)
Please note that we can’t guarantee appointments at your preferred time, but we will try our best to accommodate your preference. We have limited availability for evening appointments, so if you’re only available for evening appointments this may result in a longer waiting time.
Presenting Issues: tick those that are applicable
Presenting Issues: tick those that are applicable
Presenting Issues: tick those that are applicable
Presenting Issues: tick those that are applicable
Privacy Statement

We need to keep some information about you to give you the right support at Bucks Mind. 

When you start a service we need to know things like your name, date of birth, address and phone number so we can get to know you, work with you in the best way and contact you if necessary. We also collect information about your ethnicity, religion and gender which we use to check we are reaching all groups of people in the community.  

Other information like your GP or mental health worker and your current health and wellbeing are important so we understand how you are, how we can best support you and who to contact if we are worried about you. 

When we complete a support plan with you we may ask you what you like doing and what your goals are so we can help you achieve them. Some people’s stories and photos make lovely case studies and we may ask your permission to share these to show how our services can help people. 

We are a confidential service and want you to feel safe and respected. We will always ask you before we share information about you and we will tell you what we are doing and why. Information about you is private which is why we check with you first. If you were to become very unwell or were unable to make your own decisions (we call that lacking capacity) then we may share information if we felt you or someone else may be in danger. This may be with a GP, family member or someone else who supports you to make sure you are safe. 

We only keep information if we really need it and we look after it carefully. 

If you would like to read our full Privacy Policy, please click on the button below.

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