top of page

Home
About Us
What's On
FAQs
Referrals
Our Supporters

MALVERN HILLS WELLBEING HUB

AFFORDABLE COUNSELLING

malvernhillswellbeinghub@gmail.com

PROFESSIONAL REFERRAL

Referrer's Details

Referrer's Full Name*

Referrer's Email*

Referrer's Phone*

Referrer's Role/Position*

Referrer's Organisation*

Client Information

Full Name*

Email*

Phone

Birthday*

Day

Month

Year

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Details for referral (Please provide a brief summary of the client’s current difficulties and reasons for referral e.g. bereavement, anxiety, depression)*

What Hub services are of interest?

Face to face Counselling

Telephone Counselling

Online Counselling

Workshops or Groups

Enquire about Home Visits (for clients with mobility issues/disabilities - after risk assessment)

Women's Get Togethers

Other

Any current or past mental health support?*

Yes

Unsure

Any current mental health related medication?*

Yes

Unsure

What is there availability (tick all that apply)*

Monday AM

Monday PM

Monday Eve (Online only)

Tuesday AM

Tuesday Eve (Online only)

Wednesday Eve (Online only)

Thursday AM

Thursday Eve (Online only)

Friday AM

Friday PM

Let us know of any accessibility issues (leave blank if N/A)

I confirm that the client has given consent for this referral and understands that Malvern Hills Wellbeing Hub will contact them directly to arrange an initial appointment.

Malvern Hills Wellbeing Hub

ADDRESS

The Community Hub

Malvern Town FC

HDAnywhere Community Stadium

Langland Avenue

Malvern, WR14 2EQ

malvernhillswellbeinghub@gmail.com

Phone 07311 347057 and leave a message

bottom of page