Referral Form Play Therapy Adult Counselling
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1
2REFERRAL FORM
Play Therapy
Adult Counselling
(Please tick service required)
Date of referral
Referred by
Agency
Contact Number
Address
Postcode
Client Details
Name
Address
(inc Postcode)
Telephone Number
Mobile No
(Home)
Email address
Date of Birth
Family Members
Relationship
Date of Birth
ADULT COUNSELLING SESSIONS (If applicable)
Please state your availability for counselling sessions
Tuesday evening Yes/No
Friday am Yes/No
Wednesday Yes/No
Is a daytime (Wednesday am only) crèche place required?
Yes/No
Sessions are for 50 minutes
PLAY THERAPY (If applicable)
Please state your child’s availability for sessions
Mondays Yes/No
Tuesdays Yes/No
Wednesday Yes/No
Preferred times
11am – 1pm
1pm – 3pm
3pm - 5pm
Sessions are for 50 minutes
Revised Jun 2013
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Parent category: Medical