Referral Request for Counseling | Counselling Madrid

Therapist name:

Client: First & Last name:

Type of client:

Type of payment used by my client:

Date of my latest session with this client:

Session started at:

Type of session:

Session nr:

I am confident in my ability to support this client:

My Client is at risk of Self-harm or Harm to others

I will wait with a possible follow-up session untill after the referral has been confirmed.

Name of therapist I would like to refer the client to:

The reason for your referral request:

My referral request