Please note that we only review direct referrals from individuals seeking support themselves, unless the referral is for a child.

Name

First Name

Last Name

Subject

**Please also respond below:

Where are you? (NOTE: All ACC treatment spaces are FULL)

Age

Gender

Are you seeking ACC funded sessions? (NOTE. Our ACC books are closed, as all spaces are FULL)

If yes, have you had ACC support for sessions before?

If yes, what stage of ISSC support were you last at?

Current risk?

We are not an acute service. If you are at immediate or imminent risk, from yourself, others, or towards others: Ring 111 or Attend ED.

What professional would you like to work with?

Name of professional; Female/ Male/ Either; Clinical Psychologist/ Psychologist/ Counsellor/ Social Worker/ No preference; Experience in CBT, DBT, EMDR, IFS, ACT, Narrative, Somatic, etc.

What are you needing to work on?

For example: Low mood, anxiety, panic, addictions, nightmares, sleep and/or eating pattern, relationships, low self-worth, suicidality, non suicidal self-harm, hearing voices, etc