1SCTI Client Referral

Please fill the form below and we will be in touch shortly. Thank you.

* Indicates required field

Name Of College/University *

Course of study *

Year of study *

Your Name *

First

Last

Phone Number *

Email *

A Brief Description Of What's Going On *

I prefer my therapist to be *

Male Female I don't mind

I can afford to pay *

If other, please state what you can afford. *

Submit

Please fill the form below and we will be in touch soonest. Thank you.

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Gender *

A Brief Description Of What's Going On *

I can afford to pay *

Your generous contribution is essential to supporting the work of our therapists.

If Other, Please tell us what you can afford. *

I prefer my therapist to be *

Male Female I don't mind

Submit

Sickle Cell &
Thalassaemia Ireland

CLIENT REFERRAL FORM

STRICTLY FOR APPROVED PERSONNEL OF SCTI ONLY.

Please Fill The Form Below.

* Indicates required field

Your Name (SCTI Approved Personnel) *

First

Last

[object Object]

Client's Name *

First

Last

[object Object]

Client's Phone Number *

Client's Email *

Gender *

Female Male

Any relevant Additional Information *

Approved Number of Sessions *

Submit

For any assistance please contact [email protected]

THE INFORMATION ON THIS FORM IS HELD IN STRICT CONFIDENCE.

* Indicates required field

Name of Your Organisation *

Your Name *

First

Last

Your Email *

We will send you an acknowledgement email and the client's discharge letter.

Does this individual Reside in the Non-NEIC (Dublin North City & County) region? *

Please note that this referral pathway is for residents of Non- NEIC (Dublin North City & County) only.

Is an interpreter Required? Please state Language, or 'N/A' if not required *

Client's GP Name *

Client's discharge letter will be sent to their GP.

Client's GP Email address *

Please state Not available if you do not have this information.

Client's Name *

First

Last

Client's Phone Number *

Client's Email *

Gender *

Female Male

Medium *

In person Virtual

Please tell us how client wishes to access therapy sessions. Privacy is required for virtual.

Client would like therapist to be: *

Male Female No Preference

Any relevant Additional Information *

Submit

Please fill in the form below and we will be in touch soonest. Thank you.

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Gender *

A Brief Description Of What's Going On *

I prefer my therapist to be *

Male Female I don't mind

Submit

* Indicates required field

Your Company/Organisation *

Your Name *

First

Last

[object Object]

Phone Number *

Email *

Please briefly state your reason for seeking counselling/therapy now. *

Would you prefer a male or female therapist? *

Male Female No Preference

What time suits you best? *

Mornings Afternoons Evenings Any Time

Submit

How May We Help!

* Indicates required field

Name *

First

Last

Phone Number *

Email *

How May We Help? *

Submit

Sickle Cell & Thalassaemia Ireland

CLIENT REFERRAL FORM

Sickle Cell &
Thalassaemia Ireland