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.

Required fields are indicated by *

Who is the referral for?

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.

For example, I am her GP

Contact details of the person you're referring for counselling

For example, 3 May 1950

Is another person or organisation already providing counselling or mentoring?

We would love to stay in touch

You're helping to Beat Macular Disease, thank you. We'll use the details you have given us to provide the service or communications you have requested. We'd also love to keep you updated about how you can get involved with fundraising, events, products we sell and how we campaign.

Please tell us how you'd like to hear from us by ticking every box below that applies to you:

If you've already told us how you want to hear from us, you don't need to do anything else. You can change what you receive from us at any time on 01264 350 551 or
You can also read our privacy policy, which covers the ways that we gather, store, keep and use information about you, at