Counselling Self Referral Form – Quaggy Development Trust

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Nurseries + Information
Children Centres
Young People + Older People
- Young People
- Older People
Health Information
Counselling and Family Support
- Counselling Service
- Support for Families

Quaggy Community Counselling Service Self Referral Form

Today's date (Date of referral)

Day

Month

Year

Your name(Required)

First Last

Your date of birth(Required)

Day

Month

Year

Gender

Ethnicity

Address(Required)

Street Address Address Line 2 City Post Code

Telephone Number(Required)

Borough of Residence(Required)

Do you have child/ren under 18?(Required)

Child/ren's Date of Birth

Preferred Language

If you are pregnant what is the expected due date?

Day

Month

Year

Brief reason for your referral

Consent(Required)

I agree to be contacted regarding this referral form.

We regularly gather feedback from families who use our services. Here are some of the things they have been saying about us.

'Her sessions are very interactive and joyful.... I really like her personality and the way she engages with the toddlers'.

Parent who attended Laugh, Sing and Play.

'What a lovely session, it was amazing'.

Parent who attended Stay and Play

'Without the Children's Centre life as a new parent with no family around would be very difficult'.

Feedback from parent

'I really love the Spanish rhyme time because I want my baby to learn Spanish as it's my mother tongue'.

Parent who attended Spanish Rhyme Time

.My child had tongue tie and this group had breastfeeding experts who were invaluable in getting the help my child needed in order for me to continue breastfeeding'.

Parent who attended Infant Feeding group

'Thank you for everything you have done for my child, for everything you have taught him. For all the smiles, fun, patience, support and friendship.'

Parent whose child attended Quaggy at Parkside Nursery.

'Amazing, dedicated and friendly staff and a lot choice in terms of classes and different times offered!'

Nursery Parent

Thank you! Knowing our son has felt safe, loved, supported and learnt at Quaggy means so much to us as parents. Thanks to each one of you who has cared and looked after him.

Nursery Parent

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Registered office address: Quaggy Childrens Centre, Orchard Hill, London, SE13 7QZ