BARNET COUNSELLING ASSOCIATION
The Association of Primary Care Counsellors in Barnet
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Counselling referral formGP referring: ......................................................... Date: ........................................ Name of patient: ...................................................................................................... Address: ................................................................................................................... .................................................................................................................................... .................................................................................................................................... Telephone number: ................................................... Postcode: ........................... Date of birth: ............................................................................................................. Status of referral: Urgent q Non Urgent q Who initiated the counselling? GP q Practice Nurse q Patient q Other q Why is this patient being referred? ........................................................................ .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... Is the patient on antidepressants? No q Yes q Date of starting: ...................... Is the patient on benzodiazepines? No q Yes q Date of starting: .................... Please indicate any other health problems and medication: .............................. .................................................................................................................................... .................................................................................................................................... |