Ask for help

There is nothing wrong in asking for support. Sometimes getting some help from someone else can really make a difference.

If you would like to ask for help, or just want to have a chat with someone about how you feel please complete the form below and we will be in touch.

First Name *

Last Name *

Phone

Postcode *

Mobile

Date of Birth *

Gender

Other Gender

Which location would you like to attend? *

MELKSHAM - The Canberra Centre, 56b Spa Road, Melksham SN12 7NY
CHIPPENHAM - Station Hill Baptist Church, Station Hill, Chippenham SN15 1EG
WESTBURY - The Laverton, Bratton Road, Westbury Wiltshire, BA13 3EN
TELEPHONE - Remote telephone counselling
VIDEO - Remote counselling via Microsoft Teams

Which of the following methods are you happy for us to contact you on. *

Email
Home Phone
Mobile Phone
Text Message

Please be assured that we will never pass on your details to anyone else. They will only be used so that our Early Help and Support Team can contact you about your referral and any appointments for you to meet with us.

IMPORTANT
By submitting this referral form you are consenting to TeenTalk (Young Melksham) retaining and storing the information supplied as set out in our Privacy Policy. All information supplied is held in strict confidence and access to it is restricted only to those who require access in order to carry out their duties at Young Melksham.

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We are able to deliver our services thanks, in part, to the generous support of these organisations

TeenTalk is a service provided by Young Melksham.
Young Melksham is a company registered in England and Wales, Company Number 7871666.
Registered Office: The Canberra Centre, 56a Spa Road, Melksham SN12 7NY
Charity Registration Number: 1147394