Counselling Referral Form

Date of Referral:

Urgency: (Please select from dropdown)

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)