Booking Counselling Referrals

This form is to refer an individual for additional counselling sessions, following a course of self-referred sessions accessed confidentially via the EAP service. If you are looking to refer an employee who has had no sessions with us previously, please contact XXXX who will provide the link to the correct referral form.

These requests can arise when an individual completes their initial course and both themselves and the counsellor feel additional sessions may be beneficial. As the identity of the individual was confidential when they initially contacted us, they will have voluntarily waived their right to anonymity for this request, however the contents and reasons behind their initial self-referral will remain confidential (unless they disclose this to you).

These sessions are charged on a fee-per-session basis, in addition to your annual EAP subscription fee.

If you are concerned that you or someone you know is at immediate risk of harm. Always consider contacting/ 999 for immediate emergency support

Counselling Referral Process

Always discuss this referral with the individual before submitting a request.

When the request is received our team will liaise with the individual’s current counsellor to ensure the request is clinically appropriate. Once approved, we will instruct the counsellor to continue with the requested number of sessions. .

HR Referrer Details

(whomever is managing this referral on behalf of your organisation)

Your Organisation:

Name:

Job Title:

Contact Number:

Email Address:

Authorising Manager

(a senior manager who is authorising this referral i.e. Head of HR, Department Head etc.)

Name:

Job Title:

Contact Number:

Email Address:

Finance

Name of invoice recipient:

Job Title:

Contact Number:

Email Address:

Billing Address:

PO number (if required):

Billing Reference for invoicing (required by us)

**we cannot accept the name of any individual being referred as an invoicing reference**

Referral Details

Name of Individual being Referred:

Job Title/Department (if relevant):

Contact Number:

Email Address:

Home Address:

Date of Birth:

This Referral Form is a contractually binding order to purchase of mental health support services from Wellbeing Solutions (registered as Work Stress Management Ltd.).
Any amendments to this order must be made in writing and confirmed by an authorised representative of Wellbeing Solutions.

Outline any language, cultural or access requirements:

Is the person subject to this referral known to be at risk of harm?

Yes No

If Yes, what are the known risks at this time?

Is the person known to have caused risk to themselves or others in the last 3 months?

Yes No

If Yes, what was the risk caused?

Are there any other safeguarding concerns that you need to share?

Yes No

If Yes, what are these concerns?

Background Information (provide a summary of the referral, including information about the individual’s history):

Type of sessions required:

Telephone counselling (30 mins): £64.00 Telephone counselling (50 mins): £82.00 Video counselling (50 mins): £82.00 Face-to-face counselling (50 mins): £88.00 Couples Counselling – Virtual (50 mins): £112.00 Couples Counselling – In Person (50 mins): £122.00 Counselling with Foreign Language £112.00

Quantity of counselling sessions

Please click here if you would like us to proceed with up to 6 sessions as needed:

You will only be charged for the sessions used

Alternatively, please specify the number of sessions you wish to authorise:

CounsellingReferral

Booking Counselling Referrals

Counselling Referral Process

HR Referrer Details

Authorising Manager

Finance

Referral Details

Outline any language, cultural or access requirements:

Terms & Conditions

Counselling
Referral