Young Women's Therapy Service Referral Form

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Page 1

Are you referring yourself?

Page 2

Details of the person or service making the referral

Your relationship to the client

Name of service

Service type

Your full name

Phone

Address

Details of the person being referred / Your details if you are referring yourself

First name

Last name

Date of birth (DD/MM/YYYY)

Phone / Mobile

Email:

Address 1

Address 2

Town / City

County

Country

Postcode

Date moved in at this address if known (DD/MM/YYYY)

Consents for contact

Can we make contact by phone?

YesNo

Can we leave a voicemail message?

YesNo

Can we send a text?

YesNo

If telephone is difficult, is it better to correspond by letter?

YesNo

Alternative correspondence address

*Only if you would like us to use an address for correspondence that is different from the address provided on the previous pages of the form.

Page 3

Your Next of Kin / Significant adult

Their name

Relationship to you

Their phone number

Their address

Client's Next of Kin / Significant adult

Is the referrer also a Next of Kin?

YesNo

Next of Kin details

Name of client's next of kin

Relationship to the client

Next of kin's phone number

Next of kin's address

Your family

Do you have children under 18?

Are they living with you?

Please provide details of your children including ages

Are you or your partner pregnant?

If yes, please provide details about the pregnancy:

Client's family

Does the client have children under 18?

Are the children residing with the client?

Please provide details of the children including ages

Is the client or client's partner pregnant?

If yes, please provide details of the pregnancy:

Equality and diversity

Gender

Other gender:

Sexual orientation

Other sexual orientation:

Ethnic origin

Other ethnic origin:

Page 4

Disability and health information

Do you consider yourself to have a disability or health issue?

What is the impact of the disability or health condition on daily life?

Please limit your response to 255 characters. If you wish to write more please include in 'other details' section below.

Are there any adjustments we can make to help you access the service more easily?

Details of medication

Please limit your response to 255 characters. If you wish to write more please include in 'other details' section below.

Health information

GP Details (Name, Surgery, Address)

Physical health problems

YesNo

Physical health problem details:

Other physical health problems - details

Mental health diagnoses/difficulties

YesNo

Primary mental health diagnosis

Secondary mental health diagnosis

Referral information

Reason for referral

Please tell us about any previous experience of counselling / therapy

Other details (support needs / relevant background information)

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