Additional Counselling Sessions - Order Form

Overview

Introduction

Wellbeing Solutions provides additional counselling sessions for employees who have completed their initial course of therapy under your organisation’s EAP (Employee Assistance Programme). This service ensures continuity of care for employees who feel they need further support.

How it works

Complete and submit this referral form with all required information.
Wellbeing Solutions will contact the employee directly to arrange their additional sessions.
An invoice for these sessions will be issued to your organisation.

Key points to note

Additional sessions are charged separately from your EAP subscription.
A standard course includes up to six sessions, billed on a per-session basis.
Unless specified, the same therapist and delivery method will continue to be used.

For urgent queries, contact Wellbeing Solutions at 020 7708 5000 or email customerservices@wsm-wellbeing.co.uk.

Prices

Service	Duration	Price
Extended Telephone Counselling	50 minutes	£82.00 per session
Video Counselling	50 minutes	£82.00 per session
In-Clinic (Face-to-Face) Counselling	50 minutes	£88.00 per session

Your Organisation and HR Contact Information

Please complete all sections below to ensure we have the necessary contact details for processing this referral. These details will also be used for invoicing and follow-up communication.

Organisation name

HR referrer name

Job title

Telephone number

Mobile number (required if not office based)

Email address

Date of referral

Authorisation for Additional Counselling Sessions

Please provide the details of the manager authorising this referral. This ensures the request is formally approved within your organisation.

Authorisation same

The person making this referral is the authorisation manager

Authorising manager name

Job title

Telephone number (mobile is preferred)

Email address

Details of the Employee Being Referred

Please provide the employee’s information to ensure accurate coordination of their additional counselling sessions. All information will be handled in strict confidence, in line with GDPR and Wellbeing Solutions' data protection policies.

Employee’s full name

Job title or department

Telephone number (private mobile preferred)

Email address (personal email preferred)

Date of birth (dd/mm/yyyy)

Home address (including postcode)

Does the employee have any specific language, cultural, or access requirements?

Background information

Please make sure to only use employee’s personal contact details and not work place details

Consent confirmation

I confirm that I have discussed this referral with the employee and obtained their consent to proceed. The employee is aware that I am submitting this referral on their behalf.

Risk and Safeguarding Details

Please provide information regarding any known risks or safeguarding concerns related to the employee. This ensures we can deliver appropriate and safe support. If no risks are known, simply mark "No" in the relevant sections.

Is the employee known to be at risk of harm?

Yes No

Please describe the known risks

Has the employee caused harm to themselves or others within the last three months?

Yes No

Please provide details

Are there any other safeguarding concerns we need to be aware of?

Yes No

Please outline these concerns

Choose Your Counselling Service Options

Please select the type, delivery method, and quantity of counselling sessions required. All sessions are charged on a per-session basis and invoiced separately from your organisation’s EAP subscription.

Type of counselling

Extended Telephone Counselling – 50 minutes (£82.00 per session) Video Counselling – 50 minutes (£82.00 per session) In-Clinic Counselling (Face-to-Face) – 50 minutes (£88.00 per session)

Total number of sessions required

Full course of up to 6 sessions Specify a number of sessions

Total number of sessions required

If unsure, please select our recommended option of 'Full course of up to 6 session'.

Specify a maximum number of sessions

Billing and Invoice Details

Please complete the following details for invoicing. Invoices will be issued separately from your organisation’s EAP subscription for sessions delivered.

Invoice recipient name

Job title

Telephone number (mobile preferred)

Email address

Postal address (including postcode)

Does your organisation require a purchase order number or finance reference?

Yes No

Please provide details of the purchase order number or finance reference

Terms and Conditions for Additional Counselling Sessions

Commitment upon submission:
By submitting this referral form, the authorising manager confirms approval for Wellbeing Solutions to arrange additional counselling sessions as specified. This referral constitutes a binding contractual agreement.
Service confirmation and delivery:
Wellbeing Solutions will contact the employee directly to arrange counselling sessions based on the selections made in this form. Sessions will be delivered by qualified clinicians in line with Wellbeing Solutions’ clinical governance standards and the BACP Code of Ethics.
Confidentiality:
The employee’s identity, previously confidential under the EAP self-referral process, has been voluntarily disclosed for the purposes of this referral. All personal and session details will remain confidential and managed in line with GDPR and the Data Protection Act 2018.
Cancellation policy:
- Three or more working days’ notice: 50% of the agreed fee will be charged.
- Anything less than three working days: 100% of the agreed fee will be charged.
- Rescheduling requests made with less than three working days’ notice will incur a £50 administrative fee in addition to the standard cancellation fees.
Payment terms:
- You will be invoiced for all billable sessions outlined above upon receipt of this order.
- Invoices are due within 30 days of issuance.
- Late payments may incur interest at 4% above the Bank of England base rate, calculated daily from the due date.
Safeguarding:
Any risk or safeguarding concerns disclosed within this form will be managed in line with Wellbeing Solutions’ safeguarding policy. For immediate concerns, please contact emergency services by dialling 999.
Liability:
Wellbeing Solutions shall not be liable for indirect or consequential loss arising from the delivery of services, including delays caused by circumstances beyond reasonable control.
Clinical governance:
Counselling sessions will be provided by clinicians adhering to Wellbeing Solutions' clinical governance standards and the BACP Code of Ethics.
Amendments to This Agreement:
Any changes to this referral must be requested in writing and confirmed by Wellbeing Solutions prior to implementation.

Acknowledgment and agreement:
By checking the box below, I confirm that I have read, understood, and agree to the terms and conditions outlined above.

Terms

I agree to the terms and conditions.

Authorisation and Submission

By completing the fields below and clicking "Submit," you confirm your request for additional counselling sessions as outlined in this referral form. Upon submission:

An Adobe-signed PDF will be generated and emailed to the contact email address provided.
A copy will also be sent to Wellbeing Solutions to initiate the order process.
A member of our team will contact you shortly to finalise details and confirm the booking.

Full name

Job title

Date

Signature

Additional Counselling Sessions Referral

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Introduction

How it works

Key points to note

Prices

Your Organisation and HR Contact Information

Authorisation for Additional Counselling Sessions

Details of the Employee Being Referred

Risk and Safeguarding Details

Choose Your Counselling Service Options

Billing and Invoice Details

Terms and Conditions for Additional Counselling Sessions

Authorisation and Submission