Shopping Cart
Your Cart is Empty
Quantity:
Subtotal
Taxes
Shipping
Total
There was an error with PayPalClick here to try again
CelebrateThank you for your business!You should be receiving an order confirmation from Paypal shortly.Exit Shopping Cart

Self Referrals

If you are aged 18 or over, are female (or identify as female) and are in need of

emotional support then we may be able to help you. 


Once we receive your completed referral form, you will need to come to Chrysalis to register. Registration is every Wednesday at 11.15am and just involves registration paperwork 

and getting some information about our services.


Click on the link below to open our referral form

Self Referral Form


Once you have completed the form, download it by clicking on the download button in the top right hand corner (see image below) and choosing "With your changes".


Save it to your computer / phone / tablet then open up a new email, attach the file 

and send it to [email protected]


When using your phone you will need to download the free Adobe Acrobat app first.

Open the self referral form above, go to "share" and choose "Acrobat". It will then open in the app and you can complete the form on your phone


If you have problems with the PDF version, you can download a word version here.

Contact the office if you have any problems

Professional Referrals​

If you are a professional and want to refer one of your clients, please complete the form below to the best of your knowledge and email it to [email protected]

You can use EGRESS free if you wish to send this information securely.


We will contact your client and arrange for them to come to Chrysalis to register with us.


Professional Referral Form


If you have any problems with the PDF format you can download a Word version here


- Thank you -