Make a telephone counselling referral

We add the details you give us to our database and use them to provide the service or communications you have requested. We process and analyse your data to send you relevant information. We will never sell your data or share it with anyone not directly working on our behalf. For more information, see our privacy policy.

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Who is the referral for? *

Me Someone else

This service is for anyone affected by macular disease, or a family member of someone living with a macular condition. Our counselling service is not able to support other conditions, sorry.

About you as the referrer

Please make sure you have the person's consent to make a referral for them.

Your relationship to the person being referred

Your first name

Your last name

Your phone

Your email

I confirm I have permission of the person named below to make this referral, and they understand how their details will be used. They are aware the Macular Society will contact them directly within ten working days

Contact details of the person you're referring for counselling

First name *

Last name *

Date of birth

Phone

Email *

Address *

Address two

Address three

Town/City *

County *

Postcode *

How can we help? *

Is another person or organisation already providing counselling or mentoring?

Yes No

Please give details

Please provide brief details about the macular condition and reason for referral *

Do you have any preferred days or time for us to contact you?

Is there anything else the counsellor should know about?