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info@therapycentreservices.com
Counselling Referral Form
Online & Telephone counselling appointments will
be offered within 24 hours
Name of School
Multi-academy trust
Please select if you are part of a MAT
Central Learning Partnership
Emmaus Catholic Multi Academy Company
Leigh Trust
Our Lady of the Magnificat
Matrix Academy Trust
The Holy Family of Nazareth Catholic Academy Trust
The Holy Spirit Catholic Multi Academy
The Romero Catholic Academy
Employee's Full Name
Employee's Gender
Male
Female
Employee's Email
Employee's Phone No
Employee's internal reference
Number of sessions authorised
Referrer's Contact Name (Headteacher / Business Manager / HR Manager)
Referrer's Contact Email
Referrer's Phone Number
Reports Required
Please select..
A) None (£45 per session)
B) Initial Report only (£45 per session)
C) Initial, Interim, and Final Report (£45 per session)
D) Final Summary Report (£45 per session)
Reason for seeking therapy?
Choose an option
Abortion
Addiction
Adoption
Anger
Anxiety
Attachment disorder
Bereavement
Body dysmorphia
Bullying
Cancer
Child abuse
Complex grief
Dementia / long term illness
Depression
Disassociation
Disciplinary
Divorce
Domestic abuse
Eating disorders
Family issues
Feeling sad / SAD
Miscarriage
Loneliness
OCD
Paranoia
Personality disorders
Phobias
Physical abuse
Postnatal depression
PTSD
Relationship issues
Redundancy
Self confidence / self esteem
Self harm / suicidal thoughts
Sexuality
Schizophrenia
Stress
Trauma
Work related stress
Workplace Grievance
Has the employee been formally assessed or diagnosed with:
Choose an option
Anxiety
Bi-polar
Body dysmorphia
Dependency (drug / alcohol)
Hypomania / Mania
Gender identity
Paranoia
PTSD
Personality disorders
Psychosis
Schizophrenia
Other (please specify)
N/A
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 student 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
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