GP referral Form | Breaking Chains Counselling

GP Name

Clinic Name

GP email

Client Name

Client Email*

Client Phone Number*

Client DOB

Client Address

Emergency Contact Name

Emergency Contact Phone Number

Presenting Concerns (Tick all that apply)

Difficulty controlling pornography use

Compulsive sexual behaviour

Sexual acting-out impacting mental health

Online child sexual offending (e.g., accessing CSEM)

Contact child sexual offending

Intrusive or inappropriate sexual thoughts

Depression / anxiety

Trauma history

Relationship or marriage difficulties

Emotional regulation issues

Other (add text box below)

If “Other”, please specify

Risk Concerns (if any)

Relevant Mental Health History / Notes

Reason for Referral / Additional Notes

Please note: If referring a client for group treatment, the Mental Health Care Plan should be made out to Chamarette & Associates (Christabel Chamarette’s private practice) and emailed to them at cchamarette@gmail.com

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