Third Party Referral

Please fill in the details below and press submit for a counsellor to make contact with your client and assess how we can best support them.

Referrer Details

Name *

Agency / company you work for *

Telephone *

Email *

Relation to client: *

Why are you referring this client *

Client Basics

Preferred Pronouns

First Name *

Surname *

Date of Birth *

Gender

Ethnicity *

Sexuality *

Any Disabilities *

Telephone *

Email *

Address *

GP Surgery Name *

Emergency Contact Name *

Emergency Contact Number *

Any Medications *

Any Previous or Current Mental Health Diagnosis *

History

Has the client ever or are they currently struggling with a dependency with alcohol or drugs *

Has the client ever or are they currently struggling with any other form of dependency or addiction *

Have they ever experienced any childhood trauma *

Have they ever been a victim or witness of domestic violence *

Additional Comments

Availability

Which days are they available to receive counselling *

Which days are they 100% not available to have a counselling session *

Would they prefer an AM session or PM session *

How would they like to receive counselling

Face to Face

Telephone

Video Calls

What would they like to achieve through receiving counselling *

How did you hear about us *

How would you prefer we contact you? *

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Ratcliffe Therapeutic Counselling | ASIST Trained Crisis Support | Social Prescribing UK | Forces Specialists UK