Referral Form | It's Just a Feeling

Please find below the referral form for attending a workshop. Please fill in as much information as possible.

*Please note that you may be contacted for a short telephone chat to assess your suitability to attend the course.

Fields indicated by * are mandatory.

Date Of Referral *: Please add today's date
Client Name *
Gender *: Male Female
Date of Birth *
Age *
Client Address *: Please add your address
Postal or Zip Code *
Contact Telephone Numbers *: Please add home and mobile numbers
Email address: Please add a contact email
Referrer Details (If not self refer): Only fill in if someone other than the client themselves is referring this client. Please add Name, position, organisation, contact number and email address
Doctor's details *: Please add Doctor's name, Surgery name, Surgery address and Telephone number
Is the Doctor aware of this referral *: Yes No
Other agencies involved in care *: Please specify any other agencies, organisations or therapists involved in the care of the client. Fill in Organisational details, the name of the person who is seen and contact details for that person.
Current and personal circumstances or presenting issues *: Please add information about client current circumstances or presenting issues
Current Emotional State *: Please give indication as to client current emotional state
Other relevant information: Please add any other relevant information such as relevant history
Security *: Validation words

Please enter the validation words you see above into the box below