Name:
Address:
Phone (Home):
Phone (Work):
Phone (Mobile):
E-mail address:
What is your age:
At home:
At work:
On your mobile:
May we contact you by e-mail:
Reasons for seeking counselling:
Have you had counselling before?:
If so, when and where:
How did you hear of Life Changes?:
Employment status:
When are you available for counselling?
Monday:
AM            PM          EVENING
Tuesday:
AM            PM          EVENING
Wednesday:
AM            PM          EVENING
Thursday:
AM            PM          EVENING
Friday:
AM            PM          EVENING
Is there anything else you'd like to tell us:
May we leave a message:
Sometimes when life is hard, we can feel lonely, vulnerable and isolated. It can be hard to talk about what's troubling us, our thoughts and feelings. It may be even harder to know someone we can turn to who will listen to us without judging us.

'Life Changes', is a community counselling service situated in central Southampton, which is independent, confidential and open to all individuals over 18.
The counselling provided by 'Life Changes' offers the opportunity to reflect on life and understand the issues troubling you. You will not be judged or told what to do. Instead you will be offered the time and space to explore personal change in a private, respectful environment.

If you would like to make a request for sessions with one of our counsellors, please complete our Self-Referral Form below.
  
 

SELF REFERRAL FORM


Please complete this form and press the "send" button. Within a few days of receiving your self-referral,
our Counselling Service Director will contact you to talk through how we can best help you.
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Life Changes - Community Counselling Service
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