Counselling Referral Form Date of Referral: Urgency: (Please select from dropdown) Urgency: (Please select from dropdown)1 - Urgent2 - Priority3 - Needs Attention4 - Needs Awareness5 - Non-Urgent Person completing the Referral: Person completing the Referral: Name: Organisation: (if applicable) Contact Details: Person Requesting Counselling: Person Requesting Counselling: First Name: Last Name: Date of Birth: Phone Number: Address: Email: Postcode: Relationship to HD (please select): Relationship to HD (please select): At Risk (not tested) Gene Positive Gene Negative Symptomatic (not formally Diagnosed) Parent Partner Carer (formal/informal) Friend/Family Member Other informal network Other (please specify) Other Purpose of Referral: (Goals or issues to be addressed by counselling) Purpose of Referral: (Goals or issues to be addressed by counselling) General Emotional Support Anxiety Depression Strategies for Managing Onset of Symptoms Understanding Huntington's Disease Assistance in Supporting a Friend or Family Member Genetic Testing Process (before or after) Other (please specify) Other Please provide a brief description of your situation and reasons for counselling: 3 + 12 = Submit