/ The Counselling Foundation Referral Form
The Counselling Foundation
1 College Yard
Lower Dagnall St
St Albans
AL3 4PA
01727 868585


Thank you for your request to refer to the above service. Before completing the referral form, please keep in mind that we offer:

  • Free counselling to couples, living together or apart
  • Counselling that will focus the couple on how to increase stability in family life, improve communication, reducing anxiety in themselves and family members, and conflict resolution
  • Counselling where both people feel that there are difficulties in the relationship and for both to want to make change for improvement
  • A short term process; 6-8 sessions are usually offered.
  • This process requires couples to take time out of their normal day to attend appointments, wherever possible
  • Counselling is confidential
  • Sometimes, counselling is not the right service for all couples. If this is the case we will help you to think about what support might be better the family.
  • Please call us to discuss if you are not sure whether counselling is the right option for the family: 01727 868585

Referral to The Counselling Foundation

We would appreciate it if you could include as much information as possible on the referral form. This is to give us an opportunity to know more about the family and their needs, and to ensure that we are an appropriate service for the family. The form can be completed by the couple themselves, or by a professional who is working with the family.

If you are in any doubt about whether this is an appropriate referral or to talk through the form please contact theCounselling Foundation on 01727 868585.

Considering the above information if you feel our service is appropriate to meet the family’s needs please complete the following form. All sections need to be completed.

DATE
REFERRERS’ DETAILS
Name of Referrer / Email
Job role / Contact number
Organisation / Mobile No:

To help us to track the family’s outcomes, please include the case number of the family members for the case management system you are using. If you are using a system not listed here, please add the system name below.

ECAF / EHM / IES / Indigo Number: Parent 1
ECAF / EHM / IES /Indigo Number: Parent 2
ECAF / EHM / IES / Indigo Number: Child 1
ECAF / EHM / IES / Indigo Number: Chid 2
ECAF / EHM / IES / Indigo Number: Child 3
ECAF / EHM / IES / Indigo Number: Child 4
ECAF / EHM / IES / Indigo Number: Child 5
PARTIES WANTING COUNSELLING
Party 1 (Please indicate position in family e.g. Parent / Carer / Party 2 (Please indicate position in family e.g. Parent / Carer)
Name / Name
DOB / Age / DOB / Age
Gender / Gender
Ethnicity / Ethnicity
Current address / Current address
Post Code / Post Code
Home Phone / Home Phone
Mobile Phone / Mobile
Email / Email
Direct agreement to referral received (Please tick) / Direct agreement to referral received (please tick)
We would be grateful if you could complete the following information to enable us to evaluate the appropriateness of our service:
How would you describe the mental health and emotional wellbeing of the couple, advising us of any specific concerns or professional diagnosis of mental ill-health:
Please tell us about any concerning drug or alcohol use of either party:
Please advise us of any offending history for either party within the past two years, including any pending case:
To what extent does the conflict between the couple escalate into physical, mental, emotional or other abusive behaviour (e.g. throwing/breaking things in the home):
How does this impact on the family / child?
Has either been diagnosed with a special need or disability? If so, please describe what this is:
Please let us know of any other information you feel is relevant:
Please use an additional sheet of paper if necessary.
ADDITIONAL INFORMATION
Please describe what has happened in the family that has resulted in this referral to counselling:
How would the couple / family like counselling to help?
Where did you hear about the service?
Are there any particular days or times that are most suitable for the couple to attend counselling sessions?
Thank you for completing this form. Please return the form as follows:
By email using HertsFX:
If you do not have a HertsFX account, please email for assistance – do not send personal data using an unencrypted email system

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