Chrysalis Referral Form

Referee Name:

Agency Name:

Other : (e.g.Family Member)

Client Name:

Address:

Date of Birth:

Contact Tel No:

Has the client had prior experience of counselling/support work? Yes [ ] No [ ]

If Yes, where? Name of Organisation

What agencies are they working with at present? (Please list, voluntary, statutory etc.)

Reasons for contacting Chrysalis:

Details recorded by:

Date:

Details to be brought to team meeting on: (Date)

Staff member taking on client: