QCCS Self Referral Form – Quaggy Development Trust

Quaggy Community Counselling Service Self Referral Form

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Thank you for your enquiry to Quaggy Community Counselling Service. Please fill out the form below. Fields with * next to them are required.

Which service do you require?*

General counselling: 12 weeks of counselling available to Greenwich residents or those living locally (within a mile) of Quaggy Children’s Centre (SE13 7QZ.) Low-cost service – fees start at £2 per session.

Perinatal counselling: Free service of 8 sessions of counselling available to Greenwich residents who are currently pregnant or caring for an infant under the ages of two years.

Please confirm one of the following*

Estimated date of delivery*

Date of birth of child under 2*

Your Name*

First Last

Address*

Street Address Address Line 2 Post Code

Phone:*

Can we leave a voicemail?*

Can we send a text message?*

Date of birth*

Brief reason for your referral*

How did you hear about us?*

Other - please tell us

Quaggy Community Counselling Service Self Referral Form

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