Referral Form for Counselling: Private, Subsidised and Couples Title * Name * First Name Last Name Preferred name * Ethnicity * Date of birth * MM DD YYYY NHS number if known: Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Next of Kin and their contact information Can messages be left on the phone number you have supplied: Yes No Can we leave text messages and automatic appointment reminders: Yes No GP name and address you are registered at: Which service are you interested in: (if Subsidised Counselling – please state your income bracket). * Reason for referral/brief description of what need your treatment to focus upon: Are you a keyworker: Yes No Days Available for treatment (please be aware that we will do our best to respond to specific requests, but flexibility is encouraged to increase the speed with which you can be offered treatment) How did you hear about FCS Talking Therapies? Thank you!