Referral Form

Referral Agency/Organization

Is the referent aware that a referral has been completed:

Receiving Agency:

Additional Referral Information

Please provide the reason for referral to the Department of Counselling Services (specify any issues that need to be addressed or may be relevant when considering appropriate services for client)

What other services or interventions have been offered to the client in the past?

Please specify details of client’s involvement with your agency or other agencies and explain why.