Client Self-Referral Form

I am completing this form for myself, or with the client's explicit consent as per Leo Wellbeing Collective’s Terms of Consent*

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If you are completing this form on behalf of someone else, please add your full name here

First Name*

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Last Name*

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Date of Birth*

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GP Name & Practice (Or 'Not Registered')*

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Address*

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E-mail*

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The e-mail address is invalid

Telephone Number*

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Contact Preference & Availability Details

Do you have any medical conditions or support needs we should know about?

Have you had counselling before? What types, when, and what was the outcome?

What is your reason for seeking counselling?

Is there anything additional you would like us to know?

* Indicates required fields

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We have received your details securely. Our team will review your request and get in touch within 48 hours using your preferred contact method. We look forward to connecting with you soon.

Before You Begin: Important Information About Consent

At Leo Wellbeing Collective, we deeply value client autonomy and informed consent. We believe that therapy is most effective when the person receiving support is actively choosing it. Please review our referral criteria before completing the form:

Aged 13 and Over: Clients aged 13 and above are required to self-refer. To respect their privacy and autonomy, any referrals made by a third party (such as a parent, partner, or friend) without the client’s explicit approval and active involvement will be rejected.

Under 13s & Additional Needs: If the client is under the age of 13, or if they have additional needs that create a barrier to filling out this form independently, a representative may complete it on their behalf. In these cases, you must select the option within the form confirming that you have received explicit consent from the client to submit this request.

Thank you for helping us protect our clients' rights and build a safe, respectful foundation for therapy.