Employee Counselling Service – Online Referral

This form is ONLY for organisations using our Employee Counselling Service.

For all other referrals please go to our Referral Page.

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.
Please ensure your email address is correct as we will send a copy of this referral to you at this address for your records.

Employee 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 2 phone numbers that the employee is willing to be contacted by us on.
If you would like a copy of your referral for your records please print this page before clicking the submit button.