The Pelham Counselling Service - Professional Referral Form

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Please use this form to notify The Pelham Counselling Service of a referral for one of your clients

If you require any more information, you can contact the service directly on:

counselling@thepelham.co.uk
07907 403663
Main contact - Emma Bell

The details above can also be passed on directly to clients for signposting

Name of referral agency
*

Full Name of person referring the client to the service
*

Email of person referring the client to the service
*

Client First Name
*

Client Surname
*

Client Date of birth

YYYY

Client's phone number
*

Client's email address
*

Has the client given The Pelham Counselling Service permission to contact them?
*

Yes

Unsure

Has the client been given The Pelham's Counselling Service details?
*

Yes- they have been instructed to make contact

No- they have been told that the referral will be made for them

Reason for referral
*

Please summarise the client's current presenting issues, which they wish to engage with counselling for

Does the client wish to engage with counselling?
*

Yes

Not sure

For clients over 18 years old, please confirm that the client is in a financial position to pay for each counselling session?
Please tick all that apply
*

The Pelham Counselling Service is a fee paying service, and the financial cost for each session will form part of the initial assessment meeting

For clients 18 years old and younger, we currently have some funded sessions available, limited to 6 sessions.

Yes I confirm

The client has been told that bursaries are available to reduce cost

Not yet- these details haven't been shared

The client has been told that these sessions are free (if this is the case, you will need to inform them this is a fee paying service)

Not applicable as client is 18 or under

Required

Is the client currently engaged with, or being referred, to mental health services / health in mind?
*

If the client is under 18, this includes CAMHS and iRock.

If the client is engaged in any of these service, we will be unable to see them

Yes

Unsure

They are on a waiting list

Does the referring agency/ referrer require The Pelham Counselling Service to acknowledge that this client has engaged with the service?
*

Yes

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