Counselling Referral Form

Please confirm the date of referral(required)

Clients FULL Name(required)

Client gender/what are your preferred pronouns? (required)

Client Date of Birth(required)

We will need a method to contact you, please complete the following:

Client Email – if the client has no email facility please indicate this with n/a; otherwise please enter it here(required)

Client Phone Number

Please note when we contact you, the call will come from a withheld number. If you do not answer we will leave a voicemail unless you tell us not to. If we cant leave a voicemail an are still unable to contact you we will default to your email address. (required) I have voicemail and you can leave me a message

I do not have voicemail/please don't leave me a message

Preferred Contact Method(required) By Email

By phone

Please note that when we attempt contact, it is important for you to respond. If you do not respond this may result in your referral being closed. Calls may come from a with-held number.

Client House Number and Street [first line of address](required)

Client Town(required)

Client Post Code(required)

We know some people prefer to see a counsellor of a particular gender and where possible we can try to accommodate this, please indicate your preferences below:(required)

NOTES – briefly, in just a few words, would you like to tell us what you would like to cover during your therapy and anything else you think we may need to know.

Please indicate here if this referral is via the PHD Welfare Scheme I confirm this referral is via the PHD Welfare Scheme

If you work for PHD, please insert your staff number here

Referrer Details – if you are the person requesting support you do not need to complete this. Only complete this part if you are referring someone else.Referrer Name

Referrer Organisation

Referrer Contact Number

Referral Email

Before you click submit, please confirm the following:(required) I confirm that I have read and agree to all the terms and conditions of service listed on this site.

I am aware that this service is provided at a low cost based on my being on benefits and/or a low income and that I am happy to provide evidence of this.

I am am aware that if I do not respond to calls/voicemail/emails when contact is attempted that my referral will be closed.

If I am referring a third party I have made them aware that the cost is £1 per session.

I am aware that a fee is required for this service.