Improving Life After Brain Injury

Counselling Referral Form

Counselling Services for Acquired Brain Injury Survivors and their Carers.
  • Date Format: DD slash MM slash YYYY
  • with someone answering your phone
  • with someone answering your phone
  • (Please note that email is our preferred mode of contact)
  • Date Format: DD slash MM slash YYYY
  • Where a referral is made by an organisation, please add contact details here of the person making the referral.

    If this is a self-referral, please use this space to provide details of your GP.
  • We collect the following information about our clients for monitoring only.

    You are not obliged to complete this section.
  • Disclaimer

    Personal Data you provide on this form will be held and processed in accordance with our Privacy Policy
  • Upon receipt of this application form, if you meet the Counselling Service’s eligibility criteria, you will be offered an initial assessment appointment before we offer a face to face appointment. Counselling sessions are typically offered in blocks of 6 sessions. At the end of each block of sessions progress will be reviewed to decide if further counselling is needed.
  • Date Format: DD slash MM slash YYYY

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About Brain Injury
Contact Us

Headway Black Country:
Registered charity No: 1089171

A Company Limited by Guarantee Registered in England & Wales:
No: 4001321

Affiliated to Headway – the brain injury association, a registered charity.