Individual Referral Name * First Name Last Name Date of birth * MM DD YYYY Phone (###) ### #### Email * What gender do you identify as? * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Name of GP surgery * GP name * GP contact number * (###) ### #### Please share any medical information we should be aware of, including any medication being taken and dosage * Please put N/A if not relevant Emergency contact name * First Name Last Name Emergency contact number * (###) ### #### How do you know your emergency contact? * Have you had counselling and psychotherapy before? If so, when and what was your experience like? * Please share what is bringing you to therapy at this time. What are you hoping to address or explore? * e.g. I want my anxiety to get better, I want to fell less down all the time, I want to worry less. Please share all the days/times you are available for therapy * What fee bracket would you be happy to invest? * £40-£60 per session £60-£80 per session £80-£100 per session Are you planning on your using insurance to pay for sessions? If so, which company? Please share anything else you think we should know Please select your preferred therapy delivery method * In person Online Telephone Hybrid How did you find out about our service? * e.g. Instagram, Counselling Directory, Google, recommendation etc. Permission to phone you * So we can contact you to arrange your sessions, you need to select Yes to phone, email or text. Or you can say yes to all three. Yes No Permission to send you a text message * So we can contact you to arrange your sessions, you need to select Yes to phone, email or text. Or you can say yes to all three. Yes No Permission to leave a voicemail on your phone * So we can contact you to arrange your sessions, you need to select Yes to phone, email or text. Or you can say yes to all three. Yes No Permission to send you an email * So we can contact you to arrange your sessions, you need to select Yes to phone, email or text. Or you can say yes to all three. Yes No Referral Confirmation * Please type your name and today's date
