Counselling referral request

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Welcome to
I.M.P.A.C.T North East

(Inclusion.Mentoring.for Parents.Adolescents.Children & Teachers)

info@impactnortheast.co.uk

Home
School Services
- School services list
  - Friends Resilience Program
- Training workshops for schools
  - Mental Health Advocates
Social Care Services
- Services list
  - Friends Resilience Program
- Training & Workshops
Community Services
Fundraising
- Sky Dive for Family Mental Health
Funders & Partners
Impact Resources
Resources & self help
Shop
Gallery
Contact
Service Request Form
Questions & Quality Assurance
Privacy Policy
More
- More child

Referral Request

Please complete as much information as necessary

Name *

Address *

Phone *

Email *

Counselling request for: *

Please select one *

Message *

Additional details *

Is this referral for yourself *

Yes

No

Child

Partner

Do you have consent to make the referral *

Yes

No

Name of the person who the referral is for if not self *

some-randome-random

Quick links

EVENTS & TRAINING

ICO Ref: ZA218806

info@impactnor theast.co.uk

IMPACT Northast CIC

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0191 367 0105 / 07803595387

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SR1 1PB,