Therapy Centre Services: Kays Medical

Counselling Referral Form

in partnership with

Online & Telephone counselling appointments will
be offered within 24 hours

Employee's Full Name

Adult or Child Referral

Adult (18+)

Child (6-17)

Employee's Gender

Male

Female

Other

Employee's Email

Employee's Phone No

Date of Birth

Purchase Order No

Employee's internal reference

Number of sessions authorised

Referrer's Contact Name

Referrer's Contact Email

Referrer's Phone Number

Reports Required

Reason for seeking therapy?

Has the employee been formally assessed or diagnosed with:

Additional Information

Please select if...

The employee is experiencing suicidal ideations or feelings of wanting to self-harm

The employee has previously attempted suicide, or has self-harmed

Consent
Please confirm that you have received formal consent from the employee to share their personal information for the purpose of this referral.

The employee will be contacted directly and offered an initial appointment
within 24 hours of receiving this referral.

If you have any questions at any time, please email:
info@therapycentreservices.com