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Mental Health Support Self-referral Form

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Name
Date of Birth: Gender: Phone Number: Email: Address: City: County: Post Code:
Please provide a brief description of the reason for referral:
Please provide a brief history of the client’s mental health:
Please provide a list of any current medications the client is taking:
Has the client received any other mental health services in the past? If yes, please provide details:
Name: Phone Number: Relationship:
I, [Referrer’s Name], hereby confirm that I have obtained the client’s consent to refer them for mental health coaching services. I also confirm that the information provided in this referral form is accurate to the best of my knowledge.