Gypsy/Traveller Counselling Service

Please use this form if you are making a referral to the Gypsy/Traveller Counselling Service. On receipt of the referral by the Office, it will be sent to the Manager of the Counselling Service for action. We aim to make contact with the referred person within 48 working hours.

If you are referring someone, please complete your name, organisation, and telephone contact number

Name of person making the referral

Organization

Phone number

If you are referring yourself, please complete your name and phone number

Name

Phone number

It is important that the client is made aware/is aware that all counselling is confidential, and we will not discuss anything about them/you outside of the counselling session without your agreement, except in exceptional circumstances where we are concerned that there is a serious risk of harm to yourself or others.

Name of person being referred/self-referred *

Date of birth *

Address *

Do they/you live *

On-site

House

Roadside

Phone number *

Email *

Emergency contact

Name *

Phone number *

Has permission been given for the referral? *

yes

Date of referral *

How do you/they want to be contacted *

Phone

Both

Is it alright to leave a voice message? *

Yes

What type of counselling would they like? *

Phone support

Video

Chat

Presenting issue

Anxiety

Stress

Low-mood

Other

Any other information that you feel would be helpful for the counsellor to have (Please note that if you are referring someone, they must give consent for this information to be shared).

Thank you for filling out our form, it has been sent to us and we will get in touch within 48 hours.

Norton Park Conference Centre & Hub
57 Albion Road
Edinburgh
EH7 5QY

MECOPP

T: 0131 467 2994
E: info@mecopp.org.uk

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Minority Ethnic Carers of People Project (MECOPP) is a charity registered in Scotland - SC029700, and a registered company - SC202715.
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