Birmingham & Solihull Community Counselling Service — Refer Yourself

You can use this form to refer yourself for free counselling. Please fill it in as fully as you can. We aim to get back to you within 5 working days of receiving your form.

Please note: This is not a crisis service. If you are in immediate danger, please call 999. If you need urgent mental health support, call NHS 111 and select the mental health option.

If you have any difficulty completing this form, you can call us on 0800 599 9880 or email Gatewayfs@nhs.net — we are happy to help. Please do not submit referrals by email.

Before You Begin

Please answer the following three questions to check this service is the right one for you. If you are unsure about any of them, please call us on 0800 599 9880 and we will be happy to talk it through.

This Service May Not Be the Right Fit

If you answered No to any of the questions above, we may not be able to help — but there are other services that can:

• Under 18: Forward Think Birmingham (young people's mental health), or Kooth (free online support)
• Outside Birmingham and Solihull: Contact your local NHS Talking Therapies service or community counselling provider
• Not sure if it is a counselling need? Your GP, a social prescriber, or NHS 111 (mental health option) can point you in the right direction

If you are not sure whether this service is right for you, please call us on 0800 599 9880 — we are happy to have a conversation before you complete the form.

Your Details

How Did You Hear About Us?

About You

The following questions help us understand what you are going through. Please share as much or as little as you feel comfortable with — you can always tell us more when we speak to you.

Safety Information

We ask these questions so that we can make sure you get the right level of support as quickly as possible. All answers are treated confidentially. If you are unsure how to answer, leave the question blank and we will discuss it with you when we are in touch.

Your Preferences

There is no guarantee we can match every preference, but we will do our best to accommodate your needs.

Your Consent

How we use your information: The details you share on this form will be stored securely and will only be seen by the clinical team involved in your care. We will not share your information with anyone else without your permission, except where there is a serious concern for your safety or the safety of others. For full details, please see our Privacy Notice.

Please note: When you attend your first session, we will ask you a few more questions about your background and circumstances. This helps us to understand the communities we serve and improve our services.