Counselling Referral Form

Please read referral guidance before filling out this form.

Privacy
We treat all referrals in confidence.
FDAMH does not share any information with other organisations for their own marketing.
View our Privacy Policy for full details. You may also ask any member of staff for a copy of our Privacy Policy or view it in our Waiting Room.


Referrer Details
This information will be used to contact the referrer about the referral if necessary and to provide statistics about referrers to FDAMH.
 

Client Details
This information will be used to contact the person referred and for service provision (if taken up). It also helps us review our services.
Please provide a phone number if one is available.
Your copy
If you would like a copy of your referral for your records please print this page before clicking the submit button.