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.

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.

Referral Date

Company Name *

Referrer or Contact Name *

Referrer Email Address *

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.

Name *

Home Address *

Postcode *

Date of Birth *

Gender

Male

Female

Please provide 2 phone numbers that the employee is willing to be contacted by us on.

Phone 1 *

Phone Type

Phone 2

Phone Type

Email Address

Any other relevant information, such as access requirements

I confirm that the person referred understands what service they are being referred to and consents to this referral; and consents to the sharing of the information provided *

Tick to confirm

If you would like a copy of your referral for your records please print this page before clicking the submit button.

If you are human, leave this field blank.

Employee Counselling Service – Online Referral

Employee Details