Transform Counselling Services - Confidential Referral Form

(Couple/Family)

To access counselling/psychotherapy/systemic family practice with TCS, please complete the referral form below. You may self refer or be a professional agency completing this on the client’s behalf. This information is strictly confidential and will be stored carefully in accordance with the Data Protection Act 1998 and GDPR regulations. Following receipt of this referral form, TCS will contact you to arrange an initial consultation.

Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone

Please give the details of others who with be joining in the sessions (Name, DOB and their relationship to you)

Please briefly describe the reason/s for your referral

How did you hear about this service?

Are you asking for help for yourself? (If no, please complete the referrer section 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

Social Care

Health Professional

School Psychiatric / Health Services

Youth / Community Group

Other

If Other, please specify

GP Name

GP Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

GP Telephone

GP Email

Are you (or anyone else named on this form) taking any medication that may have an impact on the therapy process? If Yes, please give details

Are there currently any other agencies involved in the treatment/care of anyone named on this form? If Yes, please give details

What are your expectations of therapy? (If referrer, please comment on the couple/family's expectations of therapy)

Date of Referral

YYYY

Transform Counselling Services - Confidential Referral Form

(Couple/Family)

Address

Hours

Contact