Online referral form

Scroll down to fill out our online self-referral form to access our services.

Fees for Services

£55 per one-hour session (50 minutes for clinical sessions)

Please note that sessions are payable in advance.

If you are seeking support for a child (under 18) and are registered with doctors in the
Hastings and St Leonards Primary Care Network you may be eligible for up to 8 funded
sessions. Please contact your GP for eligibility and to be referred.

Referral Details

Is this a self-referral?

YesNo

Are you seeking support for someone else?

YesNo

If yes,

Referrer Name:

Relationship to Client:

Referrer Email:

Referrer Phone:

Client Details

Clients First name:

Clients Last name:

Preferred Name / Pronouns:

Date of birth:

Age:

Address 1:

Zip/Postcode:

Your contact number:

Email:

Parent/Carer Details (if under 18 and not the referrer)

Name:

Phone:

Email:

Is parent/carer aware of the referral?

YesNo

Have they given consent to be contacted by Eggtooth?

YesNo

Session Preferences

Preferred Format

Preferred Practitioner:

Availability: (Tick all that apply)

DaytimeEvening (5pm-7pm)

Services Available

Counselling & Therapy (For those wishing to speak with a qualified professional about their mental health.)

Counselling & Talking TherapyArt TherapyMusic TherapyPlay Therapy

Creative Wellbeing (Live and interactive sessions led by professional artists and creative practitioners. Please tick all that apply.)

Confidence CoachingMusic & SongwritingArt & MakingCookingBoxingSpoken Word & Creative Writing WorkshopsWalking with HorsesDJingMartial ArtsWoodland Activities

Presenting Needs and Goals

What has led you/the client to seek support at this time?

Are there any recent incidents or changes that triggered this referral?

What are your goals or hopes for these sessions

Health and Support Information

1. Are there any other services currently involved?

CAMHSChildrens ServicesOther
Please provide details:

2. Emergency Contact Details

(Please provide the name and telephone number of a next of kin, social worker, or key worker.)

Emergency Contact Name:

Their Relationship to Me/The Client:

Contact Number:

3. Are there any risk factors we should be aware of? (Please tick all that apply and provide further details below.)

I/The Client have experienced suicidal thoughtsI/The Client have engaged in self-harmI/The Client have an eating disorderMy GP has expressed concerns about my/the client’s weightThere is a family history of alcohol or substance misuseThere has been a history of domestic violence in my/the client’s immediate familySocial IsolationComplex Trauma
Further details (if applicable):

4. Am I/the client currently receiving therapy or counselling, or have I/they done so in the past?

YesNo
If yes, please provide details:

5. Health Information

Do I/the client have any diagnosed or suspected conditions? (eg ADHD/Autism)

Do I/the client have any other health concerns?

Do I/the client have any allergies?

6. Employment & Education

Am I/the client currently in employment or education?

7. Household Information

Who else lives in my/the client’s household?

8. Is there anything else you feel we should know?

Additional Information

How did you hear about us?

How would you like us to contact you? (Please tick one or more)

Phone CallText MessageEmail

We have been made aware that emails from The Eggtooth Project (info@eggtooth.org.uk) are sometimes marked as spam. Please check your junk folder if you have not heard from us within two weeks.

Data Use and Permissions

By submitting this referral form, you confirm that:

You have the necessary consent to share this information with Eggtooth, including consent from the young person (where appropriate) and/or their parent/carer.
The information provided is accurate to the best of your knowledge.
You understand that Eggtooth will use this information solely to assess and provide appropriate services.
Eggtooth will store this information securely and may share it, where necessary, with relevant professionals involved in the young person’s care, but only with appropriate consent or where required by law (e.g. safeguarding).

By checking this box, you are agreeing to our terms and conditions.

Client Testimonials

"Therapy is a godsend, regardless of whether you think you need it or not.”
Alex

"I'm less anxious, have less horrible thoughts, better mood, more positive outlook and thought process, sleep improved slightly too."
Liam

"The support I received was incredible. The therapist was understanding, patient, and truly cared about my progress. I recommend this service to everyone.” 
Aja