I CONFIRM THAT THE REFERRAL GUIDELINES HAVE BEEN READ AND UNDERSTOOD AND THAT THE DETAILS GIVEN ARE ACCURATE. I UNDERSTAND THAT ANY FALSE INFORMATION OR OMISSIONS MAY RESULT IN ANY OFFERS OF SERVICE WITHDRAWN. Signature of referrer Date 8. DECISION ON REFERRAL This section is completed by Harbour staff. Referral taken by Time/date of decision Date Entered By Who Signature of Worker Date Is the referral accepted? If no, Yes / No please give details If counselling is not appropriate, to whom has this person been referred too? 9. INITIAL CONTACT Date of First Contact Appointment Offered by: Letter Phone Call Through external agency Phone Message Other, please specify Appointment Scheduled For: Date Time Counsellor’s Name Client Code 10. ADDITIONAL NOTES, OBSERVATIONS, AND COMMENTS:
I CONFIRM THAT THE REFERRAL GUIDELINES HAVE BEEN READ AND UNDERSTOOD AND THAT THE DETAILS GIVEN ARE ACCURATE. I UNDERSTAND THAT ANY FALSE INFORMATION OR OMISSIONS MAY RESULT IN ANY OFFERS OF SERVICE WITHDRAWN. Signature of referrer Date 8. DECISION ON REFERRAL Referral taken by Time/date of decision Date Entered By Who This section is completed by Harbour staff. Signature of Worker Date Is the referral accepted? If no, please give details Yes / No If counselling is not appropriate, to whom has this person been referred too? 9. INITIAL CONTACT Date of First Contact Appointment Offered by: Letter Phone Call Through external agency Phone Message Other, please specify Appointment Scheduled For: Date Time Counsellor’s Name Client Code 10. ADDITIONAL NOTES, OBSERVATIONS, AND COMMENTS:
Harbour_Referral_form-COUNSELLING-RE05B-Dec2014.docx