Referral Forms Must Be Completed and Emailed To: WLCOH OPTIMAHEALTH.CO.UK

F-CG-130

Issue 1 draft

/ OPTIMA HEALTH / F-CG-132
Issue 1 –08/10/12(WLC Issue 209/08/2016)
Referral to Counsellor
* Please ensure these fields are completed, we are unable to process requests without this information.
SECTION 1: EMPLOYEE DETAILS
Employee No*: / Click here to enter text. / Employee’s Name*: / Click here to enter text. /
Home address*: / Click here to enter text. / Date of Birth*:
Click here to enter a date.
Sex*:
M ☐ F ☐
Job Title*: / Click here to enter text. / Email Address:
Click here to enter text.
Service Area*:
Choose an item. / Functional Area*:
Choose an item. / Telephone/Mobile Number:
Click here to enter text.
SECTION 2: DEPARTMENTAL CONTACT
do not include if completing form for a self-referral
Referring Contact Name & Job Title: / Click here to enter text. / Date of Referral: / Click here to enter a date. /
Telephone Number: / Click here to enter text. / Email Address: / Click here to enter text. /
Workaddress: / Click here to enter text.
SECTION 3:REFERRAL DETAILS
Date of Referral*:Click here to enter a date. / Type of Referral* : Choose an item.
Brief Comment: Click here to enter text.
Information on Employing Service:Click here to enter text.
Section 3: Occupational Health Only
Date Received:Click here to enter a date. / Start Date:Click here to enter a date.…
Number of Sessions:Click here to enter text.

Referral forms must be completed and emailed to:WLCOH@OPTIMAHEALTH.CO.UK

Please inform the employee that it is the Councils position that failure to keep the appointment without prior notification may result in the employee’s non-attendance being reported to their line manager, and possible disciplinary action being taken against the employee. Also the employee will be withdrawal from using the service for 6 months if they fail to attend or cancel the appointment with less than 48hours notice on two or more occasions.

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