Patient Referral Form

Patient Referral Form
Sofia Wellness Clinic is a private counselling and psychotherapy clinic in Singapore. We offer professional counselling services for children, teenagers, adults, couples and families to help them overcome life challenges and flourish as individuals. We are a team of qualified counsellors with a minimum of a Masters in Counselling committed to delivering the highest quality care to our clients.

The information that you provide here will allow us to place you with the counsellor best suited for your issues and assist you in making an appointment booking.

Website: https://sofia.com.sg
Contact: +65-66121124
Email: hello@sofia.com.sg
Patient Details
Name*

First NameLast Name
Email*
example@example.com
Contact Number*

Country CodePhone Number
Age*
Gender*

MaleFemaleNon-binaryPrefer not to sayOther
Required Service*
Preferred Appointment Format*
Preferred Appointment Day

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Preferred Appointment Time

9am to 12pm12pm to 3pm3pm to 6pm6pm to 9pm (Weekdays only)
What are you looking for help with?
If you are a referring practitioner completing the form on behalf of your patient, please use this section to share your reasons for referral and any other relevant information.
Referral Letter / Other Documents

Cancelof
Referrer Details
Name of Referring Practitioner*

First NameLast Name
Name of Company / Organisation*
Title / Designation of Referrer*
Contact Number*

Country CodePhone Number
Email*
example@example.com
Consent of Release of Confidential Information
This consent allows your treatment providers to release / exchange treatment information pertaining to you for the purpose of evaluation/assessment and/or coordinating treatment efforts.

Should you choose to consent, you may revoke your consent at any time (except to the extent that the information has already been released). Refusal to consent will not affect the quality of counselling service received in any way.

This section is optional and you may choose to complete this at a later time with your clinician at Sofia Wellness Clinic.
I consent for:

My referring practitioner to release treatment information pertaining to myself to my clinician at Sofia Wellness Clinic.My clinician at Sofia Wellness Clinic to inform my referring practitioner that I have made an appointment at Sofia Wellness Clinic.My clinician at Sofia Wellness Clinic to release treatment information pertaining to myself to my referring practitioner.I do not consent to any release / exchange of information pertaining to myself.
Signature*

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty:

Patient Referral Form

Patient Details

Referrer Details

Consent of Release of Confidential Information