Referral Form

Personal Details

First name

Last name

Gender/Preferred pronoun:

Birthday

Day

Month

Year

Address

Phone

Email

Do you work with any other agencies? (e.g. social worker, mental Health support, other support/counselling ages)

Your GP (name and surgery):

Name and telephone number of next of kin:

Previous experience of mental health support/issues:

Any health concerns that would make you a risk when having Face to Face sessions or if there anything else you think we should know (including current medication):

Appropriate support

In order for us to be able to match you with an appropriate counsellor, please answer the below questions with honesty and as fully as possible.

What is the main reason for seeking counselling and how is this affecting your daily life?

What support (if any) has already been put in place for you (home/work for example)?

Please let us know your availability (the more flexible you can be the earlier we may be able to book you in)

Please let us know which price bracket applies to you. (check as appropriate)

£25 per session if you would like to work with a student counsellor

£45 per session if you would like to work with a qualified counsellor Before 5 pm

£50 per session if you would like to work with a qualified counsellor After 5 pm

£50 per session if you would like to work with James Before 5 pm

£65 per session if you would like to work with James After 5 pm

By signing this form means you agree to the following:

I agree to this referral
I agree to information sharing with partner agencies when necessary
I agree to secure storage of my personal details

Signature

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