REFERRAL FORM FOR 8 - 13 year olds 2022

Please take some time to read this Working Agreement and Referral Form carefully.

If there is anything that you are not sure about please email our admin team at cypteam@counsellingdoncaster.com, or phone us on 07765224564.

Open Minds currently offer 10 sessions of online, telephone or in person counselling.

This form will serve as an explanation of how this approach works.

This also forms your contract, outlining the support that you agree to if you choose to press submit at the end of the form.

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Email *
For under 18s please give the name and contact details for the adult responsible for making payments where applicable:
Who is completing this form? *
If you are not the client, what is your relationship to them? Please write N/A if you are the client *
If you are not the client, do they give you consent to complete this form on their behalf? *
About You
The questions below will give us the information we need in order to best support you
Client's Name (full name please) *
Client's preferred name if different to the above *
Client's DATE OF BIRTH (day, month, year) *
Telephone number preferred for text reminders and contact from our administrative team when booking appointments. Please let us know whose phone number this is. *
Phone number on which you wish us to contact the client for telephone counselling *
Email address *
Client's Home Address *
Please provide an emergency contact name and phone number below (for us to contact this person if we felt you or someone else were in danger)
People with parental responsibility. Please give names, contact details and the person's relationship to the client  
Your registered Medical Practice (GP surgery) *
Name of School attended for under 18s   *
Appointments for Telephone and Video call therapy are available Monday to Thursday 10am to 7pm.
Please be aware that for video or telephone call therapy you need a private, quiet space in which you can talk to the counsellor.                                                                                  
Appointments for in person counselling are available for adults on Thursdays and for children on Saturdays 10am to 2pm.
Please be aware that for in person therapy you must attend your appointment at 28 Christchurch Road, Doncaster, DN12QL.                                                                    
When are you available for therapy? *
Please indicate your preferred approach to therapy *
This is my first choice
This is my second choice
This is my third choice
No thank you
I would like online counselling through video-call
I would like telephone counselling
I would like in person face to face counselling
If accessing online or telephone counselling: what address will you be at when the counsellor contacts you? Please remember to include house numbers and post code *
Do you prefer a male or female counsellor? *
Where did you find out about Open Minds please? *
What are the main issues you wish to discuss during therapy? *
What experiences in your life (recently or in the past) have caused you distress that you might want to discuss during therapy? *
What relationship difficulties (if any) might want to discuss during therapy? *
What behaviours might you want to change through therapy? *
What diagnoses of physical or mental illnesses do you have and what treatment are you receiving? *
In what ways have you tried to hurt yourself or end your life? *
When were these attempts made? *
Have you (the client) attempted suicide? *
Required
Please give us more information about your suicide attempt *
In what ways have you self-harmed or felt suicidal in the last 2 weeks? *
In what ways have you been violent towards other people and how recently was this?   *
Is there anything else you would like to add?
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