Referral Form 
Please complete this form to refer yourself or someone else for individual counselling. If you need assistance please email contacthannah@therapeutic-practice.co.uk or call 07861222487
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Referral Date *
MM
/
DD
/
YYYY
Client's Full Name *
Client's Date of Birth *
MM
/
DD
/
YYYY
Client's Gender Identity *
Client's Primary Contact Phone Number *
Client's Email Address *
Home Address *
Client's Primary Reason for Referral/Presenting Issues *
Any known risk? (Include any current risks of self-harm, harm to others, or safeguarding concerns) *
Level of Urgency for Counselling *
Client availability (any days and times that would work best or need to be avoided) *
Client's Preferred Method of Counselling *
Required
Emergency Contact *
Name and Contact Number
GP Surgery Details *
Name and Contact Number
Preferred way to be contacted *
How did you hear about me?
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