Agape Wellbeing Services

Use this form to refer a user to our services. For users registering for themselves, please use Wellbeing Service Registration instead.

Please use the form below to register for the services you are interested in. Note that services are occasionally very busy, and our numbers are limited due to social distancing measures. We will contact you if there is no space available.

    fields marked with * are required

    *Please select which group you would like to register for:

    *Your name

    *Your telephone number

    Your email address

    *Service user's name

    *Service user's telephone number


    I have completed the form as fully and as accurately as I can. I understand that this information will be deal with according to Agape Wellbeing's privacy terms and conditions: Privacy Notice


    Please enter the following letters and numbers in the box below