Referral Form

If you are a healthcare professional and would like to refer a patient to us.

Please fill out the form below…

Step 1

Step 2

Step 3

Referral Agency

Referrer’s Name

Referrer’s Telephone number

Referrer’s Email

Date of referral to CPCC

Has the client given Consent for us to contact them

Please note it is SEEN’s standard policy that consent is obtained from clients in order for us to be able to provide a support service.

Client's Name

Client's Date of Birth

Client's Gender

Client's Phone number

Client's Email

Preferred time(s) to contact

Ok to leave message

Does the client consider themselves to have a disability

If yes, please specify access or needs:

Language support needed

If yes, please specify:

Reason for Referral

Any further information you would like to provide which will help us to keep this client safe and supported

Comments

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For more information please contact us

We are an organisational membership of the British Association of Counselling and Psychotherapy (BACP) which demonstrates that we are committed to providing safe, ethical and professional counselling and psychotherapy services and training.
BACP Membership number: 00276615