Suite 202-15388 24th Ave, Surrey B.C.

V4A2J2
Phone: 604-385-0313
Fax: 604-385-0313
E-mail: chris.kellyRCC@shaw.ca

COUNSELLING REFERRAL FORM

Website: www.chriskellyRCC.com

Is this referral urgent?

CLIENT INFORMATION
Last
Name:____________________________________
First
Name:____________________________________

Sex:
Male
Female
Date of
Birth:______________________________
Country of
Origin:___________________________
Languages
Spoken:__________________________
Street
Address:_____________________________
City,
Province:______________________________
Postal
Code:_______________________________
Phone
Home:______________________________
Phone
(cell):_______________________________
Email:____________________________________
Reason for Referral (Presenting Problems):

Any relevant Medical or Psychiatric History:

Any history of aggressive behaviour, self harm or

ideation:

Date of Referral:_______________
Is client aware and agreeable to this referral? Yes No

Yes No

Referring Professional Information

Name of referring
Professional:____________________________________
Practice Name:__________________________________
Street Address:__________________________________
City, Province:__________________________________
Postal Code:____________________________________
Phone:________________________________________
Fax:___________________________________________
E-mail:_________________________________________

Other: