Vocal Psychotherapy Referral Form

Full Name

Preferred Name (If Different)

Pronouns (optional)

Date of Birth

Day

Month

Year

Address

Postcode

Phone

Email

Preferred Method of Contact

Phone

Email

Emergency Contact

Name

Relationship to You

Phone

GP Details (optional)

This information is only used if it becomes necessary in exceptional circumstances.

GP Name

GP Practice

GP Phone Number

About Your Enquiry

What has brought you to Vocal Psychotherapy at this point in your life?

What are you hoping to gain from therapy?

What was it about Vocal Psychotherapy that made you feel it might be the right approach for you?

Is there anything about your voice, emotional life or current circumstances that has led you to seek therapy now?

Previous Support & Wellbeing

Have you previously attended counselling, psychotherapy or another form of psychological therapy?

Yes

No

If yes, please tell me anything that would be helpful for me to know.

Have you ever received a diagnosis or support relating to your emotional or mental wellbeing? (Optional)

Are you currently taking any medication that you feel may be relevant? (Optional)

Is there anything about your physical health, breathing or voice that it would be helpful for me to know?

Is there anything else you would like me to know before we arrange our first meeting?

Practical Information

Preferred Days/Times for Appointments

Confidentiality

Information provided on this form will remain confidential and stored securely. There are rare circumstances where confidentiality may need to be broken, such as where there is a serious concern about your safety or the safety of another person, or where required by law. This would normally be discussed with you whenever possible.

Consent

I confirm that the information provided is accurate to the best of my knowledge.

I understand that completing this form is an initial enquiry and does not guarantee ongoing

therapy.

I understand how my information will be stored and used.

Signature

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Date

Day

Month

Year

What Happens Next?

Once I receive your completed form, I will read it carefully and contact you to arrange an initial meeting. Our first meeting is an opportunity for us to get to know one another, explore what has brought you to therapy, and consider together whether Vocal Psychotherapy feels like the right approach for you.