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Prout Bridge Counselling Service Referral Form
This is a confidential referral form to be used to access our counselling service.
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* Indicates required question
Email
*
Your email
Personal Details
This information is essential
Name:
*
Your answer
Which pronoun would you like us to use for you?
He/ Him
She/Her
They/ Them
Other *please give details in space below
Clear selection
If selected 'other' above, please give detail of preferred pronoun
Your answer
Address:
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Telephone Number (mobile if possible)
*
Your answer
Email:
*
Your answer
Emergency Contact
Required if you have a medical emergency during a session or the counsellor is concerned that you are at serious risk of harm to yourself – this would be discussed before contacting if possible.
Next of kin in case of an emergency - name, relationship to you and contact number
*
Your answer
Medical Details
This information is essential.
Contact details only for use in an emergency where client is at significant risk of harm or by agreement with the client.
Your GP is
not
automatically notified that you are receiving counselling.
Name of GP (Doctor):
*
Your answer
GP Practice Telephone Number:
*
Your answer
GP Practice Address & Postcode:
*
Your answer
Any diagnosis (physical or mental):
*
Your answer
Medication:
*
Your answer
Referral
Who is referring you
Yourself
Someone else *
Clear selection
*Name of person who has referred you if not a self-referral
Your answer
Date of Referral
MM
/
DD
/
YYYY
Additional Information
Please provide any details you wish
Are you at risk?
Are you at serious risk of taking your own life and need urgent help?
Yes
No
Clear selection
If you are at risk of taking your own life, please phone for help from
The Samaritans on 116 123 (free)
or speak urgently to your GP or a friend or family member
Are you having problems with:
Yes
No
Alcohol
Non-prescription drugs
Food
Sexuality/gender
Self-harm
Bereavement
Bullying
Domestic violence/ abuse
Suicidal Thoughts
Relationships
Violence or aggression
Depression
Anxiety
Other
Yes
No
Alcohol
Non-prescription drugs
Food
Sexuality/gender
Self-harm
Bereavement
Bullying
Domestic violence/ abuse
Suicidal Thoughts
Relationships
Violence or aggression
Depression
Anxiety
Other
Why do you want counselling now?
Your answer
Is there anything else you would like to say?
Your answer
Please tick all the times that you are available for an appointment - be as flexible as possible
Monday
Tuesday
Wednesday
Thursday
Friday
9.00-10.00
10.00-11.00
11.00-12.00
12.00-1.00
1.00-2.00
2.00-3.00
3.00-4.00
4.00-5.00
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
9.00-10.00
10.00-11.00
11.00-12.00
12.00-1.00
1.00-2.00
2.00-3.00
3.00-4.00
4.00-5.00
Evening
Please note that the counselling service is run by volunteers, who are not available every day.
The counselling coordinator may not see this form immediately, but you will be contacted as soon as possible to make an appointment.
A copy of your responses will be emailed to the address you provided.
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