Counselling Referral Form Click Here for A Printable Form Date of Referral: Is the Client Aware of this Referral?: ---YesNo Is this Referral Urgent?: ---YesNo Client Information Full Name: Gender: ---MaleFemale Age: Address: Phone (Home): Can we leave a message?: ---YesNo Phone (Cell): Can we leave a message?: ---YesNo Phone (Work): Can we leave a message?: ---YesNo Email: Emergency Contact: Emergency Contact Phone (Home): Emergency Contact Phone (Cell): Emergency Contact Phone (Work): Method of Payment / Insurer Referral Information Name of Referral Professional: Address: Phone: Fax: Email: Reason for Referral Relevant Medical/Psychiatric History Does the client have a past history of aggression? ---YesNo Do they present with self-harm or suicidal behavior? ---YesNo Please leave this field empty. Click Here for A Printable Form