Counselling referral

Information about the person needing counselling

Name

Date of birth

Gender

MaleFemaleOther

Telephone number

GP Practice

Information about who is making the referral (if different)

Name

Address (including postcode)

Telephone number

Is the person aware of this referral?

Type of referral

Is the referral for…

Bereavement counsellingCounselling for your diagnosis of a life-limiting illnessCounselling to cope with a loved one’s diagnosis of a life limiting illness

Please give a summary of the issues you would like to discuss in counselling

We provide counselling in person, online and by phone. What is your preferred method?

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