Referral Creation Wizard

Complete the following referral form to submit a request for counselling at North East Counselling .

Client

Defaults to today’s date
Select title
Enter preferred name if applicable
Enter forename
Enter surname
Enter contact number
Enter house number and street
Enter town/city
Select country
Select county
Enter full postcode (e.g BT3 9DT or SW1A 1AA)
Enter an email address.
Enter date of birth
Select gender.
Select pronoun.
If under 16 enter name and contact number
Enter name of school
Enter name of employer
Enter name of organisation
Select referral source (e.g Friend, GP, School, Self Referral etc)
Select person / organisation making the referral OR click '+' icon to add a new Referrer

 

Please select all presenting issues that apply
Please select a how did you hear about us option
Search and select your GP. Use the '+' icon below to add your gp if not found

 

Please provide brief details of why support is required.
Please tick box if you have previously had counselling
If you have used this service before, please give us some details on this.
Please provide details of days/time you are available
Please provide details of any medication, including dosage.
Please provide any additional information you feel relevant including any involvement with other mental health services

Preferences

Please select any special requirements you might need (Select all applicable).
Please select a location
Please select a project and ensure you are eligible otherwise your referral may be cancelled.
Are ground floor facilities required?
If they are, please provide some detail regarding this.

Family Members / Contacts

Contact Information

Tick if this contact may attend appointments.
Select title.
Enter forename.
Enter surname.
Enter preferred name if applicable.
Enter email address.
Enter date of birth.
Select the contacts relationship.
Select gender.
Enter contact number.
Please enter a contact number

Address Information

Tick if you would like to copy the address from the primary client.
Enter a street and house number.
Please enter a street
Optionally enter a town.
Please enter a town
Select a country
Please select a country
Select a county
Please select a county
Enter full postcode (e.g BT3 9DT or SW1A 1AA)
Please enter a valid postcode
Clear
  • No records assigned.

Consents

How we use client information

We may use client information to carry out our obligations arising from any contracts entered into by the client and us. We promise to keep your details safe and secure. We will not share your information with third parties for marketing purposes. We may contact you to let you know about other services, events or for evaluation purposes.

The circumstances when details can be shared include:

  • When a counsellor has good grounds for believing that a person may cause serious harm to themselves or others.
  • When we are instructed by a court to disclose information.
  • When a person discloses criminal activity, or knowledge of criminal activity, this includes statutory obligations.
  • When it is necessary to uphold child protection laws.

Your responsibility

We would ask that you keep us informed (by email, telephone, or in writing) of any changes in your personal data so that we may have our records up to date at all times. If you wish to withdraw your consent please contact us (by email, telephone, or in writing). You have the ‘right to be forgotten’, which means you can request the deletion or removal of personal data where there is no compelling reason for its continued processing.


GP/3rd Party Consents

I consent that you can share details with my GP and other 3ʳᵈ parties who are involved in the contract entered into by you and us

Our data is sent anonymously to the NHS so that they can track mental health in our area. The data set is used to inform service improvements and monitor service performance,
clinical interventions, patient experience and treatment outcomes. Are you happy for your data to be sent to the NHS?

Communication Consents

Tick your preferred methods of consent from the list below. Please TICK ALL that apply (a minimum of one must be selected)

I consent that I'd like to hear from you via email

I consent that I'd like to receive phone calls from you and you can leave voice messages

I consent that I'd like to receive SMS texts from you

I consent that I'd like to receive letters from you