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Please complete this form if you wish to receive counselling, being as detailed as possible so we can help you the best we can.

Please read our Counselling Support page before filling the form for full details on our counselling service, our approach, referral criteria and fees.

Even though we aim to respond sooner, our response time can be up to 10 days. Inspirited Minds is not an emergency service. If however, you require urgent attention, please follow the link here to see the various organisations you can contact.

Once you have submitted the form below you can track your support request by logging in to our Online Support Centre. Your login details will be emailed to you.

If you are a professional / organisation who wishes to refer someone for our counselling service please use our Professional Counselling Referral Form.

For any general queries –  please contact us here.


* denotes a required field

    Title *

    First Name *

    Last Name *

    Date of Birth *

    Gender *

    Marital Status *

    Employment Status *

    Organisation * (Please provide your NHS organisation)

    Religion *

    Ethnicity *

    Address *

    City *

    Postcode *

    Country * (Currently we only provide counselling to those within the UK)

    Please state whom you are seeking help for *

    Preferred Counsellor Gender *

    Preferred Counsellor Language *

    Have you been referred to us by someone *

    Who were you referred by *

    Please select which areas you would like support for *

    Please provide more details about what you are seeking help for *
    [be as detailed as you can; i.e. what form(s) of illness you suffer from, what sort of help you are seeking, what you current situation is, if you have previously or are currently receiving any support or medication]

    Telephone *

    Email Address * (Please use your NHS email address)

    Confirm Email Address *

    I am aware that my details may be shared with the team and third party advisors. I am aware that, although Inspirited Minds promise to ensure that every case is dealt with in a professional and confidential manner, in special circumstances, (eg: if it is felt that the person who contacted may be in danger or may be under-age), there may be a breach of confidentiality *

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