Referral | Therapy Centre Services

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info@therapycenterservices.com

Counselling Referral Form

Online & Telephone counselling appointments will
be offered within 24 hours.

First Name

Last Name

Email

Gender

Phone Number

Date of Birth

Ethnicity

Town/City

Job Title

Reason for Seeking Therapy

Have you been formally assessed or diagnosed with

Which day(s) are you available?

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Which time(s) are you available?

Morning (9am-noon) Early Afternoon (noon-3pm) Late Afternoon (3pm-6pm) Evening (After-6pm)

Please confirm your preferred session method

Additional Information

Please confirm that you consent to us storing and processing your personal information for the purpose of this referral.

Service Area

The Counselling service is strictly confidential and the Council will only be made aware of your service area and number of sessions, unless otherwise agreed with you in advance. This is strictly for invoicing purposes only.