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Counselling and Mentoring

Services for adults, children

and young people

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Request for Children and Young People Counselling

Please fill out the following form to access our services

Full name

Gender & preferred pronouns

Date of Birth

Service Request

Email Address

Phone

Reason for wanting support - This information is confidential to ES CIC only

I give consent for this referral to be forwarded to the team at Essential Space Counselling Community for the nature and purpose of which has been explained above. I understand any personal information shared about me will be treated as confidential, some of this information may be collected and used in an anonymous form for statistical, data or research purposes. I understand that I have (i) the right to change my mind about being referred

Today's Date

Thanks for submitting!

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