REFERRAL FORM FOR all ages paid counselling 2023

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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 onlinetherapy@counsellingdoncaster.com, or phone us on 07765224564.

Open Minds currently offer an initial 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.

Please note you are completing a form to request counselling paid at £30 per session, paid by online bank transfer.

This allows us to employ a counsellor specifically to work with the client.

Where payment is not made counselling will not continue.

Please note this is still an exceptionally discounted price for sessional counselling.

Email *

About Open Minds

Open Minds offer in person appointments, and therapy by video call or telephone.

Appointments for Telephone and video call therapy are available Monday to Thursday 10am to 7pm.

Appointments for in person counselling are available on Thursdays and Saturdays 10am to 2pm.

You and the counsellor agree on a set day and time for the appointment.

Sessions last for a maximum of 60 minutes.

The waiting list for in person appointments is typically longer than for online or telephone counselling.

How long you wait will also depend on how your availability fits to the times our counsellors can offer.

For online and telephone counselling we recommend that you find a private and quiet space in which to talk to your counsellor. If finding your own private space during the session is not possible we recommend that you cancel and reschedule for another time.

Your counsellor will use a relational approach.

They will not give you advice or tell you what to do about decisions in your life.

They may also use helpful worksheets if you and they agree that they might be of use. Please let your counsellor know if you do not find worksheets helpful.

The counsellor will help you explore the areas in your life which you choose to discuss. They will help you gain a better understanding of your experiences, relationships and what you can change. The counsellor provides a non-judgemental hour in which you can explore the issues which matter to you, at your own pace.

Open Minds’ counselling adheres to the Ethical Framework for Good Practice provided by the British Association for Counselling and Psychotherapy.

Counselling is a professional relationship and counsellors cannot accept friend requests on social networking sites from clients. We also ask that you do not electronically record the counselling session nor share the contents of your session on social media.

By ticking below you indicate you have read the above section

I confirm that I have read the above section entitled 'About Open Minds'

What we do with information about you

ICO: Open Minds is registered with the Information Commissioners Office (ICO) as a data controller and processor and work to their standards for storing information. More information can be found at: https://ico.org.uk/

Recording: The counsellor will not electronically record your sessions. This includes transcription, video and audio recording. We ask that you also not record sessions in this manner. This is due to the risk of hacking or abuse of your data if this did occur.

Note-taking: Open Minds’ use electronic note-taking. The counsellor will make notes which are stored on Open Minds’ electronic server but accessible only by the counsellor and the Managing Director of Open Minds, or which can be shared with their supervisor if there is a concern about the counsellor’s practice or your safety.

Supervision: Your counsellor will send electronic notes which will be stored securely. They may also discuss some of their work with you in order to improve the therapy you receive. You would be referred to only by your code during these discussions to maintain your anonymity. Your code is your first and last initial and your year of birth.

Information sharing within Open Minds. We may discuss your needs in triage and case review meetings within our service. This is in order to support you to find the appropriate support alongside our work with you, or if counselling might not benefit you at the current time.

Information sharing with appropriate third parties. Information sharing with appropriate third parties. Open Minds will not share information without your consent, except in the event of safeguarding disclosures. Open Minds may need to talk to the professionals who refer you, or who you name in your referral, in order to obtain sufficient information to support you internally or to identify appropriate other sources of support. We would only do so with your consent.

Breaking confidentiality

The counsellor will only share the content of your session if they are concerned about your safety or the safety of other people.

This could be for such reasons as:
1. If you are at serious risk of causing harm to yourself
2. If someone else is at serious risk from you, or from someone else
3. If child abuse is disclosed or a child is at risk of harm
4. If you share information about proposed act of terrorism
5. When compelled to do so by law

What breaking confidentiality might mean:

This might involve contacting social services, the police or another appropriate agency such as the NHS to request a welfare check. A welfare check is when a member of the police comes to see if you are safe and well.

The counsellor would normally tell you before taking this measure.

Please remember that if your counsellor has reason to believe you or someone else is at risk they must act to safeguard the people in danger

By ticking below you indicate you have read the above section

I confirm that I have read the above section entitled 'What we do with information about you'

Cancellations

We recognise that there are times when household disruption is unavoidable.

If you are unable to attend your session please email Open Minds’ admin team on onlinetherapy@counsellingdoncaster.com or text 07765 224564.

If we do not hear from you to cancel, your counsellor will, for telephone therapy, phone you from a with-held number, or for video call therapy, will attempt to contact you using the agreed online video calling platform, such as Zoom, Doxy, or MS Teams. Open Minds reserve the right to choose an alternative application if it better suits the provision of therapy.

If you do not answer they will try again in 5 minutes, and then again 5 minutes after that. If you do not answer within 10 minutes of the agreed session time the counsellor will stop trying to contact you and will wait for you to email onlinetherapy@counsellingdoncaster.com or to text 07765224564 before attempting to contact you again.

If your counsellor cannot proceed with the session due to their own illness, household disruption or problems with technology, a member of our admin team will email or text you. Counsellors do not have access to the administrative email or phone.

There will be no charge for sessions cancelled by Open Minds, nor if you cancel more than 24 hours before your session. HOWEVER if you simply do not attend without informing the team, or cancel with fewer than 24 hours' notice we will still expect payment of £30.

Please remember we are a charity and cannot afford to pay money out where it is not coming in.

By ticking below you indicate you have read the above section

I confirm that I have read the above section entitled 'Cancellations'

To make a contribution you can send the amount of £30 per session online through Bank account name: Open Minds Counselling Service sort code: 20-43-47 account number: 43096734

When you transfer the amount of money you have agreed to, please include the client's initials and year of birth as reference (for example, HM79)

There will be no charge for sessions cancelled by Open Minds, nor if you cancel more than 24 hours before your session. HOWEVER if you simply do not attend without informing the team, or cancel with fewer than 24 hours' notice we will still expect payment of £30.

Please remember we are a charity and cannot afford to pay money out where it is not coming in.

For under 18s please give the name and contact details for the adult responsible for making payments where applicable:

By ticking below you indicate you have read the above section

I confirm that I have read the above section entitled 'Payment'

Further Support

We recognise that coping in these difficult times can be challenging.

Open Minds’ waiting list may be between 3 and 10 weeks, depending on your availability.

Other sources of support are available while you wait.

Please always reach out – you deserve the support you need.

You can learn more at www.openmindslibrary.com

In the meantime you can:

- call the NHS on 01302566999

- call the Samaritans on 116123

You can access help for your mental health at:

- https://www.thecalmzone.net/

- https://www.nhs.uk/oneyou/every-mind-matters/

- https://prevent-suicide.org.uk/find-help-now/stay-alive-app/ (app to help reduce distress and suicidality)

- https://calmharm.co.uk (app to help with distress and reduce self-harm)

- https://www.kooth.com/ (KOOTH Online Counselling Service for young people aged 11-24)

By ticking below you indicate you have read the above section

I confirm that I have read the above section entitled 'Further Support'

By ticking below you indicate you have signed and accepted this working agreement. *

Yes

I have read the above contract with Open Minds Counselling Services Ltd. and agree to its terms

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) *

YYYY

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 *

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? *

Yes

I am the client

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? *

Female

Male

No preference

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? *

Yes

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?

Thank you for your time

We will contact you by text message to confirm receipt of your referral form.

We triage referrals every Thursday, so you may not hear from us until the following week.

A copy of your responses will be emailed to the address you provided.

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