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info@therapycentreservices.com
Counselling Referral Form
Online & Telephone counselling appointments will
be offered within 24 hours
Employee's Full Name
Employee's Gender
Male
Female
Other
Company name / Charity name / School name
Referrer's Contact Name
Employer's internal reference
Number of sessions authorised
Employee's Email
Employee's Phone No
Referrer's Contact Email
Referrer's Phone Number
Reports Required
Please select..
A) None (£45 per session)
B) Initial Report only (£50 for 1st session / £45 for remaining sessions)
C) Initial, Interim, and Final Report (£50 per session)
D) Final Summary Report (£45 per session / £50 for final session)
Reason for seeking therapy?
Choose an option
Abortion
Addiction (£50 Sessions)
Adoption
Anger
Anxiety
Attachment disorder (£50 sessions)
Bereavement
Body dysmorphia (£50 sessions)
Bullying
Cancer
Child abuse
Complex grief
Dementia / long term illness (£50 sessions)
Depression
Disassociation (£50 sessions)
Divorce
Domestic abuse
Eating disorders (£50 sessions)
Family issues
Feeling sad / SAD
Miscarriage
Loneliness
OCD (£50 sessions)
Paranoia
Personality disorders (£50 sessions)
Phobias (£50 sessions)
Physical abuse
Postnatal depression
PTSD (£50 sessions)
Relationship issues
Redundancy
Self confidence / self esteem
Self harm / suicidal thoughts (£50 sessions)
Sexuality (£50 sessions)
Schizophrenia (£50 sessions)
Stress
Trauma
Work related stress
Has the employee been formally assessed or diagnosed with:
Choose an option
Anxiety
Bi-polar
Body dysmorphia
Dependency (drug / alcohol)
Hypomania / Mania
Gender identity
Paranoia
PTSD
Personality disorders
Psychosis
Schizophrenia
Other (please specify)
N/A
Additional Information
Please select if...
The employee is experiencing suicidal ideations or feelings of wanting to self-harm (£50 Sessions)
The employee has previously attempted suicide, or has self-harmed
Consent
Please confirm that you have received formal consent from the employee to share their personal information for the purpose of this referral.
The employee 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
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