Reason for referral
-- select -- Abuse Alcohol Anger Anxiety Bereavement/Loss Bullying Depression Eating Problems Family Problems Gender Identity Low self-esteem Low Mood OCD Online Safety Personal Relationships Physical Health Self-harm Sexuality Suicidal Thoughts Trauma Other
If other reason for the referral, please specify
Has this person been referral previously within the last 12 months?
-- select -- Yes No
Name of Person making the Referral
Contact Details
Email of Person making the Referral
If this is an assisted referral is the person you want to refer aware of this referral?
-- select -- Yes No
Who can we speak to at home re this referral?
Who can we NOT speak to at home re this referral?
Please use the 'Ctrl' button on your keyboard to select more than one, if applicable
School Details (for children and young people referrals ONLY)
Name of School
School: Address, Phone and Email
Is school aware of this referral?
-- select -- Yes No
Are we allowed to contact the school to book a room for your session?
-- select -- Yes No
GP Details
Name of GP
GP: Address, Phone and Email
Is your GP aware of this referral?
-- select -- Yes No
Are we allowed to contact your GP surgery to book a room for your sessions?
-- select -- Yes No
Is there an Early Help Assessment (EHA) in place?
-- select -- Yes No
Are there currently any other professionals involved?
-- select -- Yes No
If yes, please can you specify the name and agency
Are we allowed to contact the above?
-- select -- Yes No
Contact details of professional involved
Any additional information
Before submitting please check 1) Phone numbers are digits only, no additional notes. 2) Postcode must be entered as example – NN8 3LT 3)The box for ‘Mobile phone’ is mobile number only 4)The box for ‘Phone number’ is for landline number only
The information provided will be used to enable us to offer the most appropriate services and actions will be kept confidential and securely stored and shared as appropriate within Service Six. Confidentiality is central to our work but it is not absolute - there are legitimate exceptions of some circumstances which require Service Six to share information with others, such as; if a person is at risk of serious harm by others; if a person is at risk of serious harm to them self or to others; or there is a risk of serious crime. A copy of our Confidentiality & Data Protection Policy is available on request or can be found on our website www.servicesix.co.uk
Some information will be used for reporting purposes; in these cases, the data will contain no identifying information that could associate you with receiving a service. Any other information will not be released without your consent unless required by law or a court order as stated above.
We are not able to offer you counselling/therapy if you are seeing another counsellor or psychological therapist, or if you are currently receiving a high level of Mental Health Care. In these cases, we might be able to offer you any other support services which is not counselling. Prior, during or after you receiving a service you can contact Service Six at 01933 277520 or send an email to referrals@servicesix.co.uk for any questions you might have. Please complete the form as fully and accurate as you can.