Counselling Services Referral Form

Counselling Services Referral Form2019-04-26T13:51:18+01:00


Next of kin contact details

GP Details

Health


Any mental health services or organisations being accessed (e.g. school, Social Services, CAMHS etc). Including any current counselling / therapy relationships.

Please note : All of our counsellors and staff are bound to confidentiality and adhere to the Data Protection Act 1998. However, should you disclose any information that relates to yourself or somebody else being in immediate danger, they are obligated to inform relevant organisations or individuals.

Please indicate by ticking ALL times when you are available for an initial appointment

Monday

AMPM

Tuesday

AMPM

Wednesday

AMPM

Thursday

AMPMEvening

Friday

AMPM

Safeguarding

Please indicate any safeguarding issues based on received information, past history and your knowledge. Please complete the below risk assessment to the best of your knowledge. It is important that we can provide a safe, supportive environment for all of our service users.

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Referred by


The information provided will be held in the strictest confidence and in accordance with Nottinghamshire Mind and GDPR guidelines and data protection policies and procedures.