Counselling Service Referral Form

Please note there is a separate referral form for the Bereavement Service.

Want to download the form instead?

Download referral form

Last updated: 9th April 2022

Consent

Has the client consented to this referral?

Please note this referral will only be processed if the client is aware and has given consent

Client details

Title

Last name

First name

Address line 1

Address line 2

Town/ city

County

Country

Postcode

Phone

Consent to leave a message

Mobile

Consent to leave a message

DOB

Sex

Ethnicity

Language

Marital status

Further information if the client is a patient

Diagnosis

Date of diagnosis

Hospital number

NHS number

Is the patient housebound?

Does the patient live alone?

Next of kin/ carer details

Last name

First name

Relationship to patient

Phone

Address line 1

Address line 2

Town/city

County

Country

Postcode

Referrer details

Must be a qualified health professional

Referrer title

Name

Phone

Address line 1

Address line 2

Town/ city

County

Country

Postcode

GP/ other services involved

GP name

Address line 1

Address line 2

Town/ city

County

Country

Postcode

Phone

Fax

Specialist Nurse name

Phone

District Nurse name

Phone

Other (please specify)

Client information

Client name

Reason for referral

Anxiety Depression Difficulty adjusting to diagnosis/treatment Body image problems Issues around caring Lack of self-confidence

Additional comments

What does the client hope to get out of counselling?

Psychiatric Care

Is the client under the care of a Psychiatrist?

Currently

Previously

Psychiatrist name

Phone

Address Line 1

Address Line 2

Town/ city

County

Country

Postcode

Are Mental Health Services involved?

Please give as much detail as possible along with contact details

Other psychological history? Previous counselling?

Please give as much detail as possible

Risk

Risk of self-harm

Risk to others

Please give as much detail as possible

Medication

Is client prescribed medication for anxiety and/ or depression?

Please list medication, start date and dose

Person completing referral

Print name

Designation

Signature

Phone

Date

Please complete ALL sections to avoid delays in processing this referral.

Helping you

Helping us

Counselling Service Referral Form

Want to download the form instead?

Consent

Client details

Further information if the client is a patient

Next of kin/ carer details

Referrer details

GP/ other services involved

Client information

Psychiatric Care

Risk

Medication

Person completing referral