Referral Form

Please confirm you have received explicit consent from the person before submitting their details via this referral form *

Yes

No

Has the parent/carer given consent for the person to receive therapy? *

Yes

No

Parental consent is not needed because the child is assessed as competent to agree

Please state if you are referring for in-person, telephone or online therapy *

In person

Online

Telephone

Hybrid

Name *

The section is all about you

First Name

Last Name

Phone *

(###)

###

####

Name *

This section is all about the person you wish to refer to our counselling and psychotherapy service

First Name

Last Name

Date of birth *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

GP contact number *

(###)

###

####

Emergency contact name *

First Name

Last Name

Emergency contact number *

(###)

###

####

What fee bracket would you be happy to invest? *

£40-£60 per session

£60-£80 per session

£80-£100 per session

Please select your preferred therapy delivery method *

In person

Online

Telephone

Hybrid

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

Would you like to speak to us before we contact the person you are referring? *

Yes

No