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Referral Form 

We are not a crisis service. Go to the Crisis Support page for sources of help, including NHS 111. 

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Please read our Client Contract and Client Consent Form before completing the referral form.

If making a referral on behalf of someone else, please include your name and contact details. ​

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If the service is not listed, then the waiting list for that service is currently closed. 

The Ryedale brief counselling service is only available to

people living in Ryedale (we are unable to process referrals from people living outside Ryedale).

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Fields marked with* must be completed.

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Self Referral
All boxes below should be completed with information relating to the client.
Can we leave a message on your phone
Appointment Preferences
How did you hear about us? Required
Client Contract - please select an option
Client Consent - please select an option

Thank you for your referral.

The Ryedale brief counselling service is only available to

people living in Ryedale (we are unable to process referrals from people living outside Ryedale)

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