Free NHS/Carer Counselling Request form

Counselling sessions are based on private self referral and are strictly confidential. No information is shared with a third party with the exception of safeguarding concerns.

The sessions will provide a confidential space to share and to express your feelings and responses to the personal challenges brought about by the current crisis situation. You can offload to someone who is trained to listen and to help you manage stress, anxiety, tension and anger which may be generated by current pressures. Also to help you hold and contain other deeper feelings that may be coming to the fore such as loss, transitions and bereavements. You will also be offered strategies to support self care and emotional well being. Counselling sessions can be arranged to fit around shift patterns with up to 6 sessions being offered to everyone, to help you do your job.

NHS/Carer Counselling                                                                                                                                                                                                                                                                                                                                                                                                                                   


*First Name:

*Last Name:

*Your Email Address:

*Phone Number:

*Date of Birth: (dd/mm/yyyy)

Role in NHS:

NHS ID Number:


Type of Carer:


Name NHS Trust or Care home company:


Preferred Days:

Preferred Times:


Reason for Request:
StressAnxietyLow MoodOther

Please specify if "other":

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