Request for additional counselling sessions - Elliott Holmes Memorial Fund

Counsellor's name(Required)

Client code(Required)

The two initials followed by age - Must match the code when referred

Date of birth(Required)

Previous session review

Is this the first time the young person has had counselling with EHMF?(Required)

Yes

No

How many sessions has the young person had to date?(Required)
Please enter a number from 1 to 20.

Date of their last session(Required)
DD dash MM dash YYYY

What was the primary focus of your initial sessions?(Required)

Why are you requesting addtional sessions? (please tick all that apply)(Required)
Unresolved issues from previous sessions
New issues have emerged
Desire to deepen work on specific goals
Need for maintenance/relapse prevention
Other

Other

Availability preferences

How many additional sessions are you seeking (up to 6)?(Required)
Please enter a number from 1 to 6.

I understand that this request will be reviewed for clinical appropriateness and funding availability.

Digital signature(Required)
Please type in your full name

Date form completed(Required)
DD dash MM dash YYYY

Confidentiality Note: The information provided in this form is strictly confidential and will be used by the clinical team to review your case and ensure continuity of care.

Elliott Holmes Memorial Fund CIC

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