Adult Referral Form Thank you for your enquiry. Please complete the form below so that we can be in touch to discuss offering an appointment. Your name Your email Telephone Address Please tick any of the following which apply; AnxietyDepressionSubstance MisuseAlcoholSelf-HarmSuicidal IdeationBorderline Personality DisorderSchizophreniaLow self-esteem/confidenceAnger managementStressRelationship DifficultiesFamily TherapyCouples CounsellingAutismADHDBipolarSelf discoveryOther - Please provide details below Depending upon our availability we will always try to offer an appointment at a time that suits your schedule. What days/times would you prefer an appointment? Please tick as many as required. Monday AMMonday PMTuesday AMTuesday PMWednesday AMWednesday PMThursday AMThursday PMFriday AMFriday PMSaturday AM Are you looking for an appointment; Video Session OnlineTelephone CallFace to Face at our clinic in Anlaby Please note, we have limited appointments available at the clinic and we may not be able to offer a face to face appointment depending upon government guidance. Availability of face to face appointments are also clinician dependent.