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Referral Form

Please complete the referral form with as much information as possible. When submitted, a dated copy is saved securely for Reach Out Remedy.

If you prefer, referrals can also be returned by email to reachoutremedy@gmail.com.

Only marked fields are required. Other fields can be left blank where they are not applicable.

Leave this field empty

Client Details

Name *This field is required* Preferred Name Date of Birth *This field is required* Gender Address Email *This field is required* Home Phone Mobile

Referrer Details

Name Organisation Relationship to client Telephone Address Email (optional)

Emergency Contact

Name Relationship to client Address Telephone Email (optional)

Reason for the Referral

Abuse Anger Alcohol Anxiety Grief / Loss Bullying Depression Discrimination Eating difficulties Family Difficulties Identity Low Self-esteem Low Mood OCD Personal Relationships Physical Health Self-harm Suicidal Thoughts Trauma Other

Other reason Please provide a detailed overview of the reasons you are seeking counselling

Health Information

Does the individual have any disabilities or support needs you would like to share?

ADHD Autism Hearing Mental Health Physical Health Sensory Sight Other

If other, please provide details

School Details (if not applicable leave blank)

School Telephone Address Email (optional)

GP Details

Surgery Telephone Address Email (optional)

Session Preferences

School Online Daytime Evening

How did you hear about us?

Website Word of mouth Recommendation Other

Other

Other Information Please include details of any other information you feel it is important for us to know