BUPA Self Referral Form

Please note, we are unable to accept a referral for the Bupa Counselling Service on behalf of someone else.
Please only enter your details in the form below.

Please select the most relevant option:

Your personal details

Your contact details

{ "addressFinderKey": "4785E0C880F84CA4B8DECB33F7C047F8", "line1": "", "line2": "", "line3": "", "province": "", "postalCode": "", "city": "", "countryIso2": "" }
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Self referral

We are unable to accept a referral for the Bupa Counselling Service on behalf of someone else. Please confirm you have completed this for yourself.
Providing Support
We'd like to create a record of your details on our database or update a record in your name that may already exist. As part of the referral process, you may share sensitive information such as details about your cancer experience and health. We will use these details to give you the best possible support every time you contact us and tailor our communications with you. Are you happy for us to record your information in this way?
If you don't want us to use your information in this way, then unfortunately we're unable to respond to your request.

Staying in touch

Thank you for contacting Macmillan. We would like to stay in touch to tell you more about our services and other ways we can support you. If you have shared any information about your cancer experience we will use this to tailor the support services we offer you.

Please contact me by (please tick):

We promise to keep your details safe and never sell or swap them with anyone. Our privacy policy explains how we keep this promise. If you don't want to hear from us, or change your mind about how we contact you, email contact@macmillan.org.uk or call 0300 1000 200.