Lamplight API response

First name

Last name

Address 1

Address 2

Address 3

Address 4

Address 5

Postcode

Email address

Mobile phone

Phone number

We would like to contact you about our services from time to time. You can opt out whenever you like, and we won't share your contact details with any other organisations. Are you happy for us to contact you:

By post

By email

By mobile

By text message

Other information

What is your date of birth

Is it ok for us to leave a message

Do you have any specific need to preference you would like to share? E.g. you may wish to see a counsellor of a specific ethnicity and/or gender.

How did you find out about our service?

What issue is a service sought for?

Ethnicity

Ethnicity, further detail

Gender

Gender, other

Do you have a disability

If yes, please tell us more about your disability

Sexual orientation

Sexual orientation, other

Have you ever had counselling before?

Safeguarding

Safeguarding concerns?

Referrer information

Referring agent contact name

Referring agent job title

Referring agency phone

Referring agency email

Referring agency address

Risk assessment

Is he experiencing/has he experienced abuse (physical, sexual, emotional, neglect, domestic, financial) Comment

State source of info if not the client (eg police officer)

Is the perpetrator known to him/have access to him (consider potential for HBV) Comment

State source of info if not the client (eg police officer)

Has an incident taken place recently? Comment

State source of info if not the client (eg police officer)

Has the current incident resulted in injury? Please state what and whether this is the first injury

State source of info if not the client (eg police officer)

Is he considered to be ‘at risk’? Comment

State source of info if not the client (eg police officer)

Is he able to access support (is there anything that may prevent him accessing support eg controlling and coercive behaviour by a perpetrator)? Comment

State source of info if not the client (eg police officer)

Is he depressed or having suicidal thoughts? Is this chronic? Comment

State source of info if not the client (eg police officer)

Is he experiencing anxiety, panic disorder? Comment

State source of info if not the client (eg police officer)

Is he exhibiting any evidence of a psychosis? If so has a diagnosis been provided?

State source of info if not the client (eg police officer)

If yes to the question above, is he accessing any support for this (either within or outside of the purview of mainstream mental health services)? Comment

State source of info if not the client (eg police officer)

Are any culturally specific issues at play (eg honour based violence/abuse)? comment

State source of info if not the client (eg police officer)

Is there evidence of self-harming/self-mutilation? Comment

Has he had problems in the past year with drugs (prescription or other), alcohol or any other compensatory measures, leading to problems in leading a normal life? If yes, please specify which and give relevant details if known

If yes, which substance please

Drugs

Alcohol

Other

Please describe further

Is he impacted by other issues as a result/or in addition to the abuse? comment

State source of info if not the client (eg police officer)

Employment

Does the client have specific needs or preferences that we can help accommodate?

Does the client exhibit mental health complications

Does the client have a diagnosis

Diagnosis

Has the client been prescribed medication for the issues being experienced

Please list

Any other health issues

Brief description of issues

Has a risk assessment been completed?

Brief description of risk – risk to self and/or others

What actions has the referral agency taken to date?

Any other agencies involved? Role?

How would the client like to be contacted?

Can we leave a message on the answer phone or send a text?

Counsellor preferred

Any Other Issues

Referrals to other agencies/other agencies involved