Counselling Referral Form Template UK

The Counselling Referral Form Template UK is designed for convenience and is available in multiple formats, including PDF, Word, and Google Docs, featuring customizable and printable options.

Open – Template

Online – Template

Sample

Counselling Referral Form Template UK

Editable – Printable

PDF – 1 PDF – 2

Counselling Referral Form Template UK

1. Referrer Information


2. Client Information




3. Reason for Referral

4. Relevant Medical History

5. Current Support Services

6. Client’s Consent

7. Confidentiality Agreement

8. Preferred Contact Method

9. Emergency Contact Information

10. Additional Notes

11. Declaration and Consent



PDF

WORD

Examples

Counselling Referral Form Template UK (1)
Referral Date:
[Date of Referral]
Referring Practitioner:
[Name of Referrer]
[Referrer’s Job Title]
[Referrer’s Organization]
[Referrer’s Phone Number]
[Referrer’s Email]
Client Information:
[Client’s Full Name]
[Client’s Date of Birth]
[Client’s Address]
[Client’s Phone Number]
[Client’s Email]
Reason for Referral:
[Detailed description of the reasons for referral to counselling, including relevant background information and specific concerns].
Client’s Consent:
I confirm that the client has agreed to this referral and understands the purpose of the counselling services they will receive.
[Signature of the Referrer]
[Date]
Preferred Counselling Outcomes:
[List any specific outcomes the referrer hopes to achieve through counselling, such as coping strategies, emotional support, etc.].
Additional Notes:
[Include any additional information that may help the counselor understand the client’s situation better, such as any ongoing treatments or support systems].
Counselling Referral Form Template UK (2)
Referral Date:
[Date of Referral]
Referring Practitioner:
[Name of Referrer]
[Referrer’s Job Title]
[Referrer’s Organization]
[Referrer’s Phone Number]
[Referrer’s Email]
Client Information:
[Client’s Full Name]
[Client’s Date of Birth]
[Client’s Address]
[Client’s Phone Number]
[Client’s Email]
Presenting Issues:
[Detailed description of the presenting issues and circumstances leading to the referral, including any specific events that prompted the client to seek help].
Client’s Goals for Counselling:
[Outline what the client hopes to achieve through counselling, such as understanding feelings, improving relationships, or managing stress].
Client’s Support Network:
[Information about the client’s support network, including family, friends, and any other professionals involved].
Confidentiality Acknowledgment:
I acknowledge that the information provided will remain confidential and used solely for the purpose of counselling.
[Signature of the Referrer]
[Date]

Printable

PDF – 1 PDF – 2

Counselling Referral Form Template UK