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Start Your Self Referal

Start your self referral

The Harbour is not a crisis service. If you are in immediate crisis please telephone 0800 953 1919 where you may speak with a practitioner working on the NHS urgent mental health helpline for Avon and Wiltshire, or you may speak with The Samaritans on 116 123.

Self Referral

Reason for seeking counselling

Please tick all that apply.

Please state the main condition or illness involved

How we store and use your data

  • Contact details, including your address, phone number and email address. 
  • Emergency contact details. 
  • Your date of birth. 
  • The name and address of your GP. 
  • Equalities monitoring information. 
  • Session notes. 
  • Information about your health and medication. 
  • Feedback from you about our service, as outlined in our Client Evaluation Form. 

We use this information to provide a safe and high-quality service to you.   

We will share your information in the following circumstances:

  • When we feel there is a risk of serious harm to yourself or someone else. In this instance we will contact you GP and/or other statutory services or service providers to let them know our concerns. When possible, we will contact you first before we do this. 

We will never share your session notes, these are confidential.

By submitting this form, you agree to The Harbour storing and sharing your data as described above. You can update your contact preferences at any time by emailing us at info@the-harbour.org.uk, or calling us at 0117 925 9348. We take your privacy seriously. You can read our Privacy Policy page here.