Professional Referral for Counselling Services
For Medical and Health & Social Care Professionals referring clients for counselling support. Please complete the confidential referral form below. All referrals are reviewed and clinically triaged by our Clinical Leadership Team. Urgent or high-risk presentations should be referred to appropriate emergency or crisis services.
Referrer Information
Title
Please Select
Dr
Mr
Mrs
Ms
Miss
Mx
Prof
Other
Other Role (please specify)
Full Name
*
First Name
Last Name
Profession
*
Please Select
General Practitioner
Psychiatrist
Social Worker
Social Care Worker
Psychologist
Occupational Therapist
Psychotherapist
Counsellor
Nurse
Other
Organisation / Practice Name
*
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client Information
Client First Name
*
Client Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Client Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client Email Address
*
example@example.com
Client Address
*
Reason for Referral
Presenting Issues
*
Is this an individual or couple referral?
*
Individual
Couple
Partner Name (if known)
Relevant Background Information
Clinical Considerations
Any known risk concerns?
*
No known risk
Suicidal ideation
Self-harm
Domestic abuse
Substance misuse
Other
Other risk concern (please specify)
Is the client currently safe to attend counselling?
*
Yes
No
Unsure
Additional risk details
Consent & GDPR
Client has given informed consent for this referral and for their information to be shared with The Couple Therapy Centre for the purposes of assessment and counselling.
*
I confirm client consent
GDPR Notice: The information you provide will be used solely to process this referral and deliver counselling services in accordance with data protection regulations. Referral information will be stored securely and only accessed by authorised personnel for the purposes of assessment, triage, and service delivery.
Submit Referral
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