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Ratcliffe & Brown CIC | ASIST Trained Crisis Support | Social Prescribing UK | Counselling Placement Provider
Facebook
Home
About us
Referrals
News
Placement opportunities
Apply
Student Library
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Testimonials
Contact us
Referrals
Referrals
We will attempt to make contact with all referral clients in 15 working days.
Name Forename
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.
This must be confirmed with the client before the referral is submitted.
Yes
No
Has the client ever or are they currently struggling with a dependency with alcohol or drugs
*
Please Select...
Yes
No
Has the client ever or are they currently struggling with any other form of dependency or addiction
*
Please Select...
Yes
No
Have they ever experienced any childhood trauma
*
Please Select...
Yes
No
Have they ever been a victim or witness of domestic violence
*
Please Select...
Yes
No
Has the client ever previously engaged or is currently engaging in self-harm
*
This must be confirmed with the client before the referral is submitted.
Yes
No
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.
This must be confirmed with the client before the referral is submitted.
Yes
No
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
*
Please Select
AM
PM
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?
*
Please Select...
Telephone
Email
Text Message
Please ensure you have filled out all required fields.
Submit
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×
×
×
×
×
×
×