Counselling Referral Form

    Date of Referral:

    Is the Client Aware of this Referral?:

    Is this Referral Urgent?:

    Client Information

    Full Name:

    Age:

    Address:

    Phone (Home):

    Can we leave a message?:

    Phone (Cell):

    Can we leave a message?:

    Phone (Work):

    Can we leave a message?:

    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?

    Do they present with self-harm or suicidal behavior?