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Coffee in Nature

Clinical Counsellor

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Thank you for

referring!

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Formal Referral Form

Thank you for your referral! Formal referrals are accepted from teachers, all medical and allied health practitioners, social workers, or parents/legal guardians. Consultation session is complimentary, and all clients are pre-screened for suitability based on age and presented mental health needs.

Please obtain verbal consent for information to be shared for the purpose of intake.

Client Legal Name

Referring Party Name and Agency

Client Phone

Client Date of Birth

Parent/legal guardian name/contact (if under age 19)

List any known/suspected diagnosis and reason for referral

List any additional referral information

Initials

Today's Date

I have obtained verbal consent for the purposes of referral

Thanks for submitting!

Covid-19 Health Declaration

To be completed the morning of the session. How are you or your child feeling today? For minors, please use your child's name below.

First Name

Last Name

Email

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat

I haven’t been in close contact with a Covid-19 patient in the last 14 days

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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