Transform Counselling Services - Confidential Referral Form

(Adult)

To access Counselling/Psychotherapy with TCS, please complete the referral form below. You may self refer or be a parent/carer, professional agency or school to complete this on the client’s behalf. This information is strictly confidential and will be stored carefully in accordance with GDPR. Following receipt of this referral form, TCS will contact you to arrange an initial assessment.

Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Please briefly describe the reason/s for which you require counselling:

How did you hear about this service?

Are you asking for help for yourself? (Please tick). If no, please complete referrer details below:

Yes

Referrer Name

First Name

Last Name

Referrer Organisation

Referrer Position

Organisation Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Organisation Type

Parent /Carer/Family

Social Services

Health Professional

School

Psychiatric / Health Services

Youth / Community Group

Other

Please specify

Medical Information

- GP Name - GP Address - Post Code - GP Telephone Number - GP Email Address

Are you currently taking any medication that you consider would have a significant impact on the counselling process? If so, please state below:

Date of Referral

YYYY

Transform Counselling Services - Confidential Referral Form

(Adult)

Address

Hours

Contact