Make a counselling referral

Our counselling service is here to support you.

Please complete the referral form below to request a confidential session with one of our qualified counsellors. Our counselling team will review your request and aim to respond within five working days.

Who our counselling service is for

Our free telephone counselling is available to anyone in the UK over 18 who is:

Living with macular disease or Charles Bonnet syndrome (CBS)
Struggling emotionally with diagnosis, sight loss, or daily challenges
A family member or carer affected by a loved one’s diagnosis

Please note: This is not a crisis service. We cannot offer counselling if you are currently receiving therapy elsewhere, in a mental health crisis, under psychiatric care, or need specialist mental health support.

Referring on behalf of other person?

If you are referring another person, please make sure you have their consent before completing this form.

Required fields are indicated by *

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Who is this referral for? *

Me Someone else

Contact details for the person receiving counselling

First name *

Last name *

Address *

Address two

Address three

Town/City *

County *

Postcode *

Email *

Our referral form requires an email to be submitted. If you don’t have one, please use: client@macularsociety.org - this is a placeholder to help process your referral. You will still receive counselling support by phone, and no emails will be sent to this address.

Phone *

Can we leave a message on your voicemail? *

Yes No

About your counselling service

Please select the condition(s) you are seeking counselling for (tick all that apply)

Macular disease

Charles Bonnet syndrome (visual hallucinations)

Please briefly describe the reason for your referral or request for counselling *

Additional information

Answering these questions is optional and won’t affect the support you receive. Your responses will help us learn more about who we’re supporting and how we can improve our services.

Date of birth

Self-describe (please enter below):

Other ethnic group (please enter below):

Referrer details

We will only contact you if we need to clarify any information or we cannot get in touch with the person being referred.

Your name

Your phone

Your email

I confirm I have permission of the person named above to make this referral, and they understand how their details will be used.

Please note if the above is left unticked, your referral will not be passed on.

We collect your contact details and information about your macular condition so we can provide you with the best possible support. We also ask for some additional information to help us understand who we’re supporting and how we can improve our services in future. For more information on how we collect, store, and use your data, please read our privacy policy at macularsociety.org/privacy.

We’ll use the information you’ve provided to deliver the services requested. For more information on how we collect, store, and use your data, please read our privacy policy at macularsociety.org/privacy.