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Ratcliffe & Brown CIC | ASIST Trained Crisis Support | Social Prescribing UK | Counselling Placement Provider
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About us
Referrals
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Contact us
Referrals
Referrals
Name Forename
All referrals will be acknowledged within 48 hours of receipt.
Name
*
Preferred Pronouns
*
Agency / company you work for
*
Telephone
*
Email
*
Relation to client:
*
Why are you referring this client
*
SP Project Only
*
This is for social prescribers only. Click No for any other clients.
Select an option...
YES
NO
Client Basics
First Name
*
Surname
*
Preferred Pronouns
*
Date of Birth
*
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
Ensuring Safety In Communications
If we left a voicemail message and someone else heard it, would that put you in danger?
*
This is to understand any safety risks associated with contacting a client and to ensure we work safely with them.
Select an option...
yes - It would put me in danger
No - It wouldn't cause a problem
I don't want messages left on voicemail
Working Contract
Confidentiality
*
The content of your counselling sessions is confidential. The only limits to confidentiality are if you were to inform us of an imminent risk to your life or another or alert us to a serious crime, in which case the counsellor must inform the safeguarding officer. Please confirm if you agree to our confidentiality rules.
Select an option...
Yes
No
Counsellors
*
In Ratcliffe & Brown CIC, our counsellor team consists of trainee counsellors in their last or second-to-last year of qualification. They are supervised and supported by qualified counsellors and clinical supervisors. Please confirm if you agree to work with our trainee counsellor team. If you wish to work only with a qualified counsellor, please see the link below to our sister company, Ratcliffe Therapeutic Counselling. The team of qualified counsellors and specialists can further support your complex journey. Prices are available to view on the website.
Select an option...
Yes
No
GDPR
*
All your information is stored securely in line with GDPR and kept for five years after completing your counselling journey with us. After this point, it is confidentially deleted.
Select an option...
Yes
No
Please ensure you have filled out all required fields.
Submit
×
×
×
×
×
×
×
×
