Referral Form

1Tell us about yourself

2Why you are referring

3Medical background

Are you making this referral for yourself?
- Yes - for myself
- No - I am a third party
Please note that if you are a third-party organisation you will need to send us an email with further information about your client. Also when referring someone there is a minimum £15 donation towards counselling.
Third party
Third party name*
First Last
Third party phone
Third party email*
About you
Name*
First name Last name
Your address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Date of Birth*
DD slash MM slash YYYY

Medical background
Current Medication*
Relevant physical conditions*
Do you smoke?*
- Smoker
- Non-smoker
Ethnicity
First Language*
Ethnicity
Next of Kin (optional)
Relationship
Name
First Last
Phone
Your GP (optional)
GP Name
GP Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
GP Phone
Consent
I consent for you to contact my GP
Finally ...
Further notes
Further notes that might help us such as a trauma or incident
How urgent is your referral?*
On a scale of 1 (low) to 10 (high), how urgent is your referral

Third party