Counselling Referral Form

Counselling Referral Form
Client Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityCounty

Postal Code
Date of Birth

DayMonthYear
Date
Email
example@example.com
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Method of Contact
Relationship Status
Referral Name (if applicable)

First NameLast Name
Emergency Contact Information
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Relationship
Medical Information
Are you currently taking prescription medication?
Prescribing Doctor's Name and telephone number

NameTelephone number
If yes, please briefly explain what the medication is:
Have you seen a counsellor, psychologist, psychiatrist or other mental health professional before?
If yes, please briefly explain why and if you found it helpful:
Reason For Counselling
Is this counselling for you?
If it is not for you, please state who it is for.
Which of the following do you need counselling or therapy for?
Please explain briefly what the main issues are for seeking counselling?
What are your main goals to be achieved during counselling?
When would you like the counselling to start?

Other
Please state the best times and days that you would prefer:
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful and that you are happy to be contacted by admin to process your referral for an appointment
Date

DayMonthYear
Date
Signature
Should be Empty:

Emergency Contact Information