Due to confidentiality, Please make sure when referring you use the correct form, either Self or Professional.
If you are referring through a professional body, you must use this Professional Referral Form. Self referrals please complete below.
After filling out the Self Referral From below, you will initially be contacted by one of our trained counsellors via Email. If you prefer to be contacted another way please specify.
Self Referral Reason
Please provide Medical History if applicable
Do you have any Medical Problems that we should be aware of?
Are you currently taking any medication?
Please tick the type of medication
By submitting this form I accept the information provided will be held by SAFA. This information will be kept confidential, however there are some extreme situations where SAFA may be obliged to share information.
Please note that referrals are usually reviewed by a counsellor within two working days (Monday-Friday)
By ticking this box, I confirm my consent as stated above