Lamplight API response

Why does the family being referred want Counselling?

Name of Referrer if not self

Email address of Referrer

Relationship of client to referrer

Is there a history of any Domestic Abuse in the family

If yes, please provide more details

Name of Family Member 1 (Main Contact)

Address Family Member 1 (if different to families)

Mobile Number Family Member 1 (if different to families)

DOB Family Member 1

Gender (Family Member 1)

Ethnic Identity (Family Member 1)

GP Surgery Family Member 1

Are they dependent on drugs or alchohol? (Family Member 1)

Do they have any diagnosed mental health conditions? (Family Member 1)

Are they suicidal? (Family Member 1)

Do they self-harm? (Family Member 1)

Do they have a diagnosed eating disorder? (Family Member 1)

If yes to any of the above please give details (Family Member 1)

Do they have autism

Do they have ADHD

Name of Family Member 2

Address Family Member 2 (if different to families)

Mobile Number Family Member 2 (if different to families)

DOB Family Member 2

Gender (Family Member 2)

Ethnic Identity (Family Member 2)

GP Surgery Family Member 2

Are they dependent on drugs or alchohol? (Family Member 2)

Are they suicidal? (Family Member 2)

Do they have any diagnosed mental health conditions? (Family Member 2)

Do they self-harm? (Family Member 2)

Do they have a diagnosed eating disorder? (Family Member 2)

If yes to any of the above please give details (Family Member 2)

Do they have autism?

Do they have ADHD?

Name of Family Member 3

Address Family Member 3 (if different to families)

Mobile Number Family Member 3 (if different to families)

DOB Family Member 3

Gender (Family Member 3)

Ethnic Identity (Family Member 3)

GP Surgery Family Member 3

Are they dependent on drugs or alchohol? (Family Member 3)

Do they have any diagnosed mental health conditions? (Family Member 3)

Are they suicidal? (Family Member 3)

Do they self-harm? (Family Member 3)

Do they have a diagnosed eating disorder? (Family Member 3)

If yes to any of the above please give details (Family Member 3)

Do they have autism?

Do they have ADHD?

Name of Family Member 4

Address Family Member 4 (if different to families)

Mobile Number Family Member 4 (if different to families)

DOB Family Member 4

Gender (Family Member 4)

Ethnic Identity (Family Member 4)

GP Surgery Family Member 4

Are they dependent on drugs or alchohol? (Family Member 4)

Do they have any diagnosed mental health conditions? (Family Member 4)

Are they suicidal? (Family Member 4)

Do they self-harm? (Family Member 4)

Do they have a diagnosed eating disorder? (Family Member 4)

If yes to any of the above please give details (Family Member 4)

Do they have autism?

Do they have ADHD?

Name of emergency contact

Relationship to client

Phone Number of emergency contact

Names and details of any additional family members

Mobile Number of Referrer

Other information