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Online Referral Form for Lena’s Counselling and/or High Intensity Services

To contact Lena’s counselling service you can:

Call us 24/7, 365 days a week, on 0800 389 5362

Use the chat function on any page of this website between 10am – 4pm, Monday to Friday

Use the online self-referral ‘Add me’ form below and a member of our team will call you back

Online Referral Form for Lena’s Counselling and/or High Intensity Services

Lena needs to gather the information below so that we can register you on our case management system. All our records are held in compliance with EU and UK GDPR/Data Protection Law and Requirements. Click here to view the Inspire (our charitable parent organisation) Privacy Policy which we operate under.

You will be automatically notified when you complete and submit this form, and a member of our team will be in touch to complete the process.

If you are completing this form on behalf of someone else, please ensure the details you enter below are those of the person who is looking for support, and that you have their consent to share their information with us.
If you require more immediate support please contact your helpline number – or if you find yourself in crisis, or in an emergency, please call 999.

Employing Organisation(Required)

First & Second Name(Required)

Gender(Required)

Date of Birth(Required)

Email Address(Required)

Mobile(Required)

Please prefix with/include your international dialling code ie 44 for Northern Ireland/UK numbers or 353 for Ireland numbers

GP Name & Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Preferred Location(Required)

Please state the nearest town/city to where you wish to be seen. We will endeavour to accommodate your preference however not all services are available in all areas.

By checking the relevant box below and submitting this form, you are consenting to Lena keeping a record of your information. This is to enable us to correspond with you to complete the referral process, arrange appointments, and the ongoing delivery of treatment. You can read about how we keep your data protected in our Privacy Policy.(Required)

Yes, I give my consent

Yes, I have consent (if completing on someone’s behalf).

Phone

This field is for validation purposes and should be left unchanged.

Mental health toolkit

Mental health tools can help you identify patterns and triggers so you can monitor and improve how you feel

See your toolkit