Referrals

We will attempt to make contact with all referral clients in 15 working days.

Referrer Details

Name *

Preferred Pronouns *

Agency / company you work for *

Telephone *

Email *

Relation to client: *

Why are you referring this client *

Client Basics

First Name *

Surname *

Preferred Pronouns *

Date of Birth *

Ethnicity *

Sexuality *

Any Disabilities *

Telephone *

Email *

Address *

GP Surgery Name *

Emergency Contact Name *

Emergency Contact Number *

Any Medications *

Any Previous or Current Mental Health Diagnosis *

History

Is the client currently under CMHT for treatment * If a client is currently working with CMHT they are unlikely to be suitable for working with trainee counsellors and so are unsuitable for referral.

Has the client ever or are they currently struggling with a dependency with alcohol or drugs *

Has the client ever or are they currently struggling with any other form of dependency or addiction *

Have they ever experienced any childhood trauma *

Have they ever been a victim or witness of domestic violence *

Has the client ever previously engaged or is currently engaging in self-harm *

Provide the details in regards to the client's self-harm history * If not applicable, please just write N/A.

Has the client ever previously experienced or is currently experiencing suicide ideation * It is unethical for trainee counsellors to work with actively suicidal clients. If the client you wish to refer is currently suicidal, you will need to seek support through our sister company, Ratcliffe Therapeutic Counselling, to work with qualified counsellors.

Provide the details in regards to the client's suicide history * If not applicable, please write N/A.

Additional Comments

Availability

Which days are they available to receive counselling *

Which days are they 100% not available to have a counselling session *

Would they prefer an AM session or PM session *

How would they like to receive counselling

Telephone

Video Calls

Face to Face

What would they like to achieve through receiving counselling *

How did you hear about us *

How would you prefer we contact you? *

Ratcliffe & Brown CIC | ASIST Trained Crisis Support | Social Prescribing UK | Counselling Placement Provider

Referrals

Referrals

Referrer Details

Client Basics

History

Availability

Quick Links

Contact Us

Ratcliffe & Brown CIC | ASIST Trained Crisis Support | Social Prescribing UK | Counselling Placement Provider

Referrals

Referrals

Referrer Details

Client Basics

History

Availability

Quick Links

Contact Us

Follow Us