Referral Form

Your Full Name:

Date of Birth: (required)

Full Address (including postcode): (required)

Phone: (required)

Can we leave a message? (required)
—Please choose an option—YesNo

Email Address:

Contact preference? (required)

Please note, your preferred contact method may not always be suitable for every contact and an alternative may need to be used.

—Please choose an option—PhoneEmailTextWhatsAppPost

When is best to contact? (required)

Preferred Language
—Please choose an option—EnglishWelshOther

If other, please specify:

Ponthafren’s Services

- Counselling is a talking therapy that involves a trained therapist listening to you, helping you discover ways to deal with emotional issues.

- Our One-to-One Recovery service provides practical support on a one-to-one basis to help you live your best life, achieve your goals, and move forward. We can offer support with many areas including amongst many others housing, budgeting/debt, attitude to life, confidence issues, and managing physical health.

- SilverCloud is an online programme that helps you to develop ways of managing your own emotional wellbeing. It is based on Cognitive Behavioural Therapy (CBT) which focuses on the way in which thoughts can influence feelings and behaviours. SilverCloud can be delivered online only or by blending online with personal contact with a member of our staff to help guide through the programme.

- Our Life Skills group courses aim to help you understand your personal mental health and develop healthy coping strategies and emotional skills.

- Volunteering is not just about helping others or giving to your community. It can also boost your wellbeing by improving your confidence, teaching you new skills, helping you meet new people, or as a flexible step towards or away from paid work.

If you have an idea of which of Ponthafren’s services interest or would help you, please tick any that apply.

CounsellingOne-to-One Practical SupportBlended Online CBT (SilverCloud)Life Skills GroupsVolunteeringWork Placement / Experience

Please tell us what you need help with? (required)

About the Referrer

Please ignore this section if this is a self-referral.

Regarding other organisations: It is the responsibility of the referrer to get consent to make this referral. Ponthafren may need to speak to the referrer for further relevant referral details, regarding waiting times, or to notify of client non-attendance/referral closure. If the person being referred has not consented to this, please make this a self-referral and do not provide referrer contact details below.

Name of referrer

Referring organisation

Contact Number

Email Address

For further information on how your referral relates to data protection, please visit our referral privacy notice at
www.ponthafren.org.uk/privacy-notice-referral-form