Date of referral:

Counselling Referral Form

Full Name: Ashley Jordan Reid

Address: 8 Clarke Mansions Upney Lane Barking Essex IG11 9QJ

Date of Birth: 22/10/1991

Contact Number: 07309626755

Email: Ashleyjordanreid@gmail.com

Tick all that apply: ☐Depression or mood changes ☐School Problems

☐Suicidal ☐Work Problems
☐Major Mental Illness ☐Relationship Problems
☐Self-Harm ☐Family Problems
☐Anxiety ☐Personality Changes
☐Legal Issues ☐Alcohol
☐Withdrawal ☐Drugs
☐Chronic Relapse ☐Anger
☐Disordered Eating ☐Low Self-Esteem
☐Greif/Loss ☐Other:
☐Housing Issues
☐Poor Support

By signing this form, you authorise Smile Of A King Foundation to forward this
information onto a qualified counsellor.

Sign: Date: 27/03/2023

For Office Use Only

Counsellor Assigned:
Invoice Total:
Date Invoice Paid:
Number of sessions paid for: