Counselling Self-referral Form

General Information

This application form is used to apply for counselling at Projekt 42.  To complete the form takes less than 5 minutes.

To help you access counselling with the right person, we need to collect some personal information.  Where we collect sensitive information, we do so only to provide the service to you.  Under the Data Protection Act 2018, your permission is needed to collect and keep persnal data, whether by manual or elctronic means.  By completing and submitting this form, you give us the necessary permission to keep such dat as you are willing to disclose.

Don't worry; if you change your mind, you can exercise your rights under the Genral Data Protection Regulation May 2018, and you can ask Projekt 42 to delete any information we hold for you.  You can do this anytime by sending an email to data@projekt42.co.uk.  for further information relaating to Data Protection, Projekt 42's Privacy Policy, Procedure for Subject Access Requests, email data@projekt42.co.uk.

About You

In order to help you access counselling, we need to know a little information about you.

Contact in case of Emergency

Sometimes, with your permission, we will contact someone who cares about you. Who would you like this to be? We won't ever contact this person without your permission.

Your Therapy & Preferences

Each counsellor is trained in a range of counselling, life coaching and psychotherapy approaches. This enables us to tailor our approach to suit your learning style, giving you the best opportunity for positive results.

The range of therapies we provide includes counselling, psychotherapy, cognitive behavioural therapy (CBT), psychodynamic.

At the time of meeting a member of our counselling team, we will discuss the options available to you, from long-term therapy to short-term counselling.

Please tick the issue(s) that you feel apply to you. Areas that you highlight below can be talked through with your counsellor. The issues below do not need to be diagnosed conditions but relate more to how you feel and what you feel is effected your mood. Feel free to also explain what difficulties you are currently experiencing in the next question below.

GP Consent

There may be occasions where, with your permission, we can contact your GP to let them know that you are working with our counselling team.

Costs, Payment & Cancellation Terms

We ask, where possible, those community members who can pay/contribute to their counselling in line with their own income.  Where needed, you can also select our free counselling option.  The cost of a counselling session is based on a sliding scale from £25.00 to £55.00 per session depending on your annual gross income:


Based on my income, I will pay *

Under  £20,000   ->          £25.00 per  counselling session  

£20,000 - £24,999  ->      £35.00 per counselling session         

£25,000 - £29,999  ->      £45.00 per counselling session     

£30,000 - £34,999  ->      £50.00 per counselling session        

Over £35,000    ->           £55.00 per counselling session

I want to request free counselling and can confirm I am not in full-time education or full-time employment.

*To reduce the number of first appointments that are not attended, we ask everyone to pay £25 towards the first appointment.

Payment & Cancellation Terms

Sessions must be paid for in advance of your appointment and any appointment cancellations must be made at least 48 hours before your appointment. Missed sessions must be paid for. This is to ensure that the charity's costs are covered.

How did you hear about Projekt 42?

What happens next

When you submit the self-referral form, you will receive an email to confirm that we have received your form.  If we require any further information, the Projekt 42 Mental Health team will contact you.  Where possible, we will email you; please check your inbox and junk folder for any updates from us.

We aim to work with clients within 4-weeks of receiving your self-referral, and when you receive your first initial appointment, we will provide you with a brief overview of what you can expect from the counselling services at Projekt 42.

If you have any questions, please email us at mentalhealth@projekt42.co.uk.