Counselling Referral Form for Health Professionals

Counselling Referral Form for Health Professionals
This form is for the use of health professionals who want to refer a client for counselling, and it is not possible for the client to complete the self-referral form themselves.

If the client is willing to complete their own self-referral form, please direct them to:

Self-Referral Counselling Request Form

Pregnancy Counselling & Care Scotland (PCCS) offers free, professional counselling to anyone struggling in relation to pregnancy or early parenthood. Issues we regularly support people with include pre-conception counselling, infertility, pregnancy support, stillbirth, miscarriage, and termination.

If you want more information about the two services we offer please visit our website www.counsellingandcare.co.uk
Referrer Details:
Name*

First NameLast Name
What organisation do you work for? (If you are NHS staff, could you inform us of your office/practise base)*
Your role?*
Is this your first time making a referral with us?*

YesNo
Email*
example@example.com
Phone number*
Please confirm you have consent to share details about your client?*

YesNo
Counselling Request:
Client name*

First NameLast Name
Gender
Phone number (we do sometimes contact clients by telephone)*
Email - please note we will contact clients via email as our main contact method*
example@example.com
Are they interested in our long-term counselling or fast-track service?*

Long-TermFast TrackUnsure
Please include a brief description of the reason you are referring your client, it really helps us when setting up their appointment*
Our Fast Track sessions are delivered online.

Our Long-Term sessions are delivered online or in person. In person sessions are currently held a 1 Lochside View, with availability weekdays from 8am-7pm.

Please let us know which types of counselling they would be interested in?*

	Yes	No	Maybe
Online counselling
Face to face counselling (Lochside View)

And which method of counselling would they prefer?*

Online counsellingFace to face counsellingDon't mind
Do they have any other questions or concerns that they would like to raise with us at this time?
How did they hear about our service - was it from you, their referrer?*

YesNo
If yes, please mark your profession, if no, please indicate how they first heard of our service?*

Word of mouthGPHealth VisitorOther medical Professional (please specify role below)Web searchFacebookInstagramVia our Baby Bank serviceOther organisation (please specify below)Other (please specify below)Prefer not to say
Please specify further details where required from above response
Should be Empty: