Counselling Referral Form

Date of Referral:

Is the Client Aware of this Referral?:

—Please choose an option—YesNo

Is this Referral Urgent?:

—Please choose an option—YesNo

Full Name:

Gender:

Age:

Address:

Phone (Home):

Can we leave a message?: —Please choose an option—YesNo

Phone (Cell):

Can we leave a message?: —Please choose an option—YesNo

Phone (Work):

Can we leave a message?: —Please choose an option—YesNo

Email:

Emergency Contact:

Emergency Contact Phone (Home):

Emergency Contact Phone (Cell):

Emergency Contact Phone (Work):

Method of Payment / Insurer

Name of Referral Professional:

Address:

Phone:

Fax:

Email:

Does the client have a past history of aggression?

—Please choose an option—YesNo

Do they present with self-harm or suicidal behavior?

—Please choose an option—YesNo