Counselling Referral Form

Online & Telephone counselling appointments will be offered within 24 hours

Company name / Referrer name / Charity name / School name

Client's Full Name

Client's Gender Required

Female

Male

Other

Referrer's Contact Name

Referrer's internal reference:

Number of sessions authorised:

Client's Email

Referrer's Contact Email

Client's Phone No.

Referrer's Phone No.

Additional information:

Please select if...

The client is experiencing suicidal ideations or feelings of wanting to self-harm

The client has previously attempted suicide, or has self-harmed

The client will be contacted directly and offered an initial appointment within 24 hours of receiving this referral.

If you have any questions at any time, please email: info@therapycentreservices.com

Thank you, your counselling referral has now been submitted.

We will be in touch with the client shortly to offer an initial session.

Tel/Text : 07895 796857