Private Individual Referral - The Talking Rooms - Counselling & Psychotherapy in Glasgow

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1About You

2Contacts

3Referral

4State of Wellbeing

5Sessions

6Referrer

7Submit

PLEASE NOTE THIS IS A PAID FOR SERVICE.

Initial Appointment/Consultation £50. If you are a suitable candidate for therapy you will start with a commitment of six sessions which is £399. This is payable in full in advance following initial consultation. If your therapist isn't suitable for any reason you can arrange another initial appointment with another practitioner. We do not take insurance or offer a payment plan currently. We have a strict 48 hour cancellation policy, your session will be counted if the session is cancelled within 48 hours of your planned session. We also contract you to be free of substances for 12 hours prior to your session time. We offer both in person and face to face. You will be contacted following this completed referral to arrange a suitable time and date for your initial session - this may sometimes be from a withheld number. We will try and leave a message, we will also email (check your junk just in case) and SMS. Please respond promptly as appointments do go quickly.

Referral Type*

Please fill in all fields with the referred's details - you will have an opportunity to fill in your details before submitting.

Name*

First Last

Phone*

Email*

How Do You Identify?*

Date of Brith*

DD slash MM slash YYYY

Age Group*

Address*

Street Address Address Line 2 City Post Code

Your GP

GP Name or Name of Surgery*

Surgery Address

Street Address Address Line 2 City Post Code

Your Emergency Contact

Emergency Contact Name*

First Last

Emergency Contact Phone*

Your Relationship to the Emergency Contact*

What is the Reason for Your Referral?*

Costs & Payments

PAYMENT IN ADVANCE OF SESSION (48HOURS) **COSTS PER SESSION FACE TO FACE £65** COSTS PER SESSION ONLINE £55** Please note that this is a paid service. We operate on a pay-as-you-go basis, meaning you pay for each session at least 48 hours before your scheduled appointment. Additionally, we enforce a 48-hour cancellation policy. Upon arranging your first appointment, we will collect your card details, and payment will be charged for late cancellations or no-shows. The costs for private counselling and CBT remain the same. Our online sessions are available from 8 am to 9 pm and are conducted by highly qualified and experienced therapists. Face-to-face sessions are held in Glasgow or East Kilbride, also from 8 am to 9 pm, and are facilitated by skilled professional therapists. Please also be aware that we offer a discount for bulk purchases, so feel free to discuss this option if you're interested in buying a group of 6 sessions or more.

Do you have a medical or mental health diagnosis that you are aware of?*

Do you consider yourself to be at risk of harm to self or to others at this time?*

Are you currently considering suicide?*

Have you made a plan to end your life?*

For urgent mental health support please contact your local GP or NHS 24 on 111.

Or contact one of the following crisis services:

Samaritans: 116 123
Breathing Space: 0800 83 85 87
Scottish Women's Aid: 0800 027 1234
Rape Crisis: 08088 01 03 02

Are you considering or engaging in self harm?*

Are you currently receiving treatment or support from another service?*

Are there any barriers that would stop you from accessing weekly treatment?*

Are you currently attending work?*

What would be your session preference?*

Online

Face to Face – Glasgow (Morris Park J1 M74)

Face to Face – East Kilbride (EK Business Centre)

Select all options that may be suitable.

When would be a good time for your sessions?*

Monday Morning

Tuesday Morning

Wednesday Morning

Thursday Morning

Friday Morning

Monday Afternoon

Tuesday Afternoon

Wednesday Afternoon

Thursday Afternoon

Friday Afternoon

Monday Evening

Tuesday Evening

Wednesday Evening

Thursday Evening

Select as many as you wish

Can you advise if you will be able to take a regular weekly slot at an agreed day and time.

Yes

Unsure work shifts

Can you advise if your preference would be weekly, fortnightly or monthly sessions.

Weekly

Fortnightly

Monthly

Which type of service are you looking for?

Cognitive Behavioural Therapy

Person Centred Counselling

Integrated Counselling

Unsure

Consultation*

Select All

Morning

Afternoon

Evening

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

We will call you to discuss your referral and book your first appointment. You can use this time to ask any questions with the therapist who calls you. Please list when generally is good for us to give you a call. (Please also note - we generally call from a withheld number, we will leave a message.)

What is your relationship to the referred?*

Referrer Name*

First Last

Consent of the Referred*

I confirm that I have the consent of the referred to submit a referral on their behalf

Is there anything you would like to add?

How did you hear about our service?*

Personal Data Consent*

I confirm that I have read and understood how the personal data submitted in this form is handled and retained The Talking Rooms' Privacy Policy .

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First Choice

Second Choice

Third Choice

Phone

This field is for validation purposes and should be left unchanged.