SELF-REFERRAL

First name

Last name

Birthday

Day

Month

Year

Email

Phone

Address - Please include your postcode as a minimum so that we can confirm that we can offer you our services .

How would you like to be contacted?

Phone

Email

Either

Is there anything you would like us to know before we contact you ? You do not need to tell us about your personal circumstances or mental health at this stage. We can discuss these with you when we make contact. Do not include sensitive information.

What Hub services are of interest?

When are you available? (tick all that apply) ONLY Indicate Times that you can attend . We allocate sessions depending on your availability and you will be expected to be available during the times indicated .

Please let us know of any accessibility requirements below (leave black if N/A)

Counselling Session Contributions

The MHWH is charitable incorporated company run by volunteers and counsellors . We are funded by Platform housing , The National Lottery, Malvern Town Council ,MHDC and the CO OP with rooms donated by Malvern Football club . The client contribution is not only an investment in yourself and your future , but allows us to keep supporting the community and keep the hub open . We appreciate times are hard at the moment , but we are doing our very best to keep costs to a minimum and still be able to keep running . The requested client contributions are set at the very minimum to comply with our grant funding . Thanks for your support and understanding .

A £10 contribution for the first session/assessment paid in advance to your allocated Counsellor is required .

Contribution options

Income UNDER £20 000 and able to pay £10 contribution per session

Income OVER £20 000 and able to pay the £20 a session contribution

Income OVER £30 000 and able to pay £30 a session

Would like to apply for concession

Would like to apply for a concession to reduce client contributions after the initial session ( form will be sent out requesting further information )

Privacy and Data Protection

By submitting this form, you confirm that the information you have provided is accurate to the best of your knowledge and that you understand Malvern Hills Wellbeing Hub CIC will use it to process your referral and contact you about counselling or wellbeing support.

Your information will be handled confidentially in accordance with our Privacy Policy, which you can find in the FAQ section of this website.

I confirm that I have read and understood the Privacy Policy .

Client Commitment

I understand that I am agreeing to be available for weekly sessions at the same time and day each week and confirm I have only indicated times I am available . I understand that counsellor will attempt to make contact twice before I am removed from the waiting list and that they will be allocated to me dependent on what times I have agreed I am available . .

MALVERN HILLS WELLBEING HUB

SELF-REFERRAL