Spectra Psychosexual Counselling Referral Form
We cannot accept this referral unless we are provided with the following information.
Information about Person Completing Referral
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: 000 0000 0000.
GP Practice / Medical service
*
GP Contact Details
Individual Information
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Is Individual aware of this Referral?
*
Yes
No
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: 000 0000 0000.
Gender
*
Man/Male
Woman/Female
Agender
Non-Binary
Not sure
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal Code
Interpreter required?
*
Yes
No
If yes, what language?
Any accessibility issues?
*
Please indicate if there are any safeguarding concerns
*
Please indicate if the client is on the sex offenders register
*
Referral Information
Counselling Service Interested
Please Select
Psychosexual Counselling
Reason for referral (Please tick issues that apply)
*
Erectile dysfunction (Assumes Croydon CCG pathway adhered to)
Delayed ejaculation
Premature ejaculation
Vaginismus
Anorgasmia
Arousal problems
Loss of libido (assumes endocrine causes ruled out)
Sexual pain (non-organic)
Avoidance – fear or anxiety engaging in sex
Sexual compulsive disorders
Risky sexual behaviours
Other
How did you find us
Full Referral Details
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