Welcome to our Online Referral Forms page. We understand that taking the first step to seek support can be daunting, and we want to make the process as easy and accessible as possible. Our online referral forms provide a secure and confidential way to reach out for the support you need. Whether you are a survivor looking for counseling,an individual seeking support for someone you care about or a professional making a referral for someone in your care, our online referral forms are designed to cater to your specific needs. Rest assured that your information will be handled with the utmost care and privacy.
By filling out our online referral forms, you are taking a significant step towards healing and empowerment. Let us walk this journey with you – complete the form now to get started.
*please note we can only take referral from the Stoke-On-Trent area.
Choose the Appropriate Form: Depending on whether you are a survivor seeking support or a professional making a referral, select the relevant form.
Provide Your Details and Relevant Information: Fill in your name, contact information, and any other required personal details.
Submit the Form: Once you have filled out the required fields, click the “Submit” button to send the form to our team.
Follow-Up: Our dedicated team will review your referral promptly and reach out to you or the individual referred to discuss the next steps to book an initial options appointment (IOA) .
*Please Note: we can only take referrals if the named person on the form is aware of the referral. Referrals made via our online referral service will only be accessed during office hours 9am – 5pm Mon – Fri.
Unit C, Metro Business Park,
Clough Street, Hanley
Monday 9 am–8 pm
Tuesday 9 am–8 pm
Wednesday 9 am–5 pm
Thursday 9 am–5 pm
Friday 9 am–5 pm
Saturday 9 am–2 pm
Phone: 01782 433204 / 433205