This application is to refer yourself or a loved one into Compassion Clinic - a pro bono service for those in need.
Click the button below to start.
Question 1 of 5
How did you hear about us?
Friend or family member
Treating Professional - GP, counsellor
Question 2 of 5
Contact details - please provide below your full name, postal address, email address, phone number (including area codes)
Question 3 of 5
Please briefly describe the reason for your application today:
Question 4 of 5
Please list any current treating professionals:
Question 5 of 5
Please describe your goals or outcomes ie: support, help to get back on track, Guidance.