Referral type Self referralAgency referral
Name of person referred *
Address *
Town *
Post Code *
Email *
Telephone Number *
Date of Birth *
Gender FemaleMalePrefer not to say
Are you employed *
How would you like to receive your counselling? * TelephoneVideo CallFace to Face
Preferred area for counselling * MansfieldNewarkWorksop
Name *
Current health issues and medication taken
Disability : If yes, please state
Has the client/yourself accessed counselling before? NoYes
If you answered Yes to the above point, please give more details including how long ago you completed your counselling.
Any mental health services or organisations being accessed (e.g. school, Social Services, CAMHS etc). Including any current counselling / therapy relationships.
Names of organisations
Telephone number
Reason for referral/presenting issues *
Clients aims for counselling? What do you wish to gain from accessing counselling?
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
Wednesday
Thursday
AMPMEvening
Friday
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.
Risk to Self Harm * NoYes
Comment*
Past history or abuse/traumatic experience that affects current moods and behaviours * NoYes
Risk to others (violence towards others) * NoYes
Risk to property (damage to property, theft, other) * NoYes
Comment *
Drug misuse * NoYes
Alcohol misuse * NoYes
Physical health issues - any health issues or medication we may need to be aware of *
Name of referrer
Position / Team
Email
Telephone Number
Has consent been given by the client for information to be shared NoYes
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.
Please leave this field empty.
