Counselling Services Referral Form

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

Next of kin contact details

Name *

Address *

Town *

Post Code *

Telephone Number *

GP Details

Name *

Address *

Town *

Post Code *

Telephone Number *

Health

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

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.

Risk to Self Harm *
NoYes

Comment*

Past history or abuse/traumatic experience that affects current moods and behaviours *
NoYes

Comment*

Risk to others (violence towards others) *
NoYes

Comment*

Risk to property (damage to property, theft, other) *
NoYes

Comment *

Drug misuse *
NoYes

Comment*

Alcohol misuse *
NoYes

Comment *

Physical health issues - any health issues or medication we may need to be aware of *

Referred by

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.