Exclusive 1:1 Executive Leadership Support for CEOs Referral Form (Online)

Thank you for considering Dr. Elaine Smith’s bespoke 1:1 support services, specially designed for CEOs, executives, and senior leaders. Each individual session is priced at £295, offering high-touch guidance to empower you as a leader and enhance your well-being in today’s demanding business environment.

This confidential referral form ensures your experience is personalised to address your unique leadership challenges and needs, helping us craft a support plan tailored specifically to you.

We also offer the following exclusive session packages:

  • 1 Session: £295

  • 3 Sessions: £850

  • 8 Sessions: £2,200

These sessions are available online, offering flexibility to fit seamlessly into your schedule, no matter where you are.

By completing this form, you’ll help us provide you with the clarity, resilience, and strategic insight you need to excel.

Rest assured, your information will be treated with the highest level of discretion and confidentiality.

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Email *

Are you referring yourself, or someone else?
(Multiple choice)


Clear selection
Name of Person Being Referred: 
 *
Address: *
Date of Birth: 
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YYYY
Date of Referral 
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Telephone Number
Telephone Number:
Preferred Package/No. of Sessions:
 *
Do you consent to this referral?
 *
Source of Funding
 *
Required
Employer: 
Invoice Details 
(Name, Address, Purchase Order if applicable)
(indicate N/A if self-funding and same details as above apply)
Please ensure you have also included the email address to send the invoice to if employer funded. 
 *
GP Contact Details:
 *
Reason for Referral 
What are the main problems/issues? 
Some details that you think will be helpful before we start working together.  
 *
Other Health Professionals Involved?:
How did you hear about Dr. Elaine Smith?: 
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