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Refer a Client
Self Referral
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Refer a Client
Refer a Client
All fields marked with an * must be filled
I confirm I have permission from the client to make this referral and provide their information to Lifelink to use to process the referral?
Client Has Given Permission For Referral
*
Client Has Given Permission For Referral
No
Client Has Given Permission For Referral
Yes
Currently seen by Mental Health Professional
*
Currently seen by Mental Health Professional
No
Currently seen by Mental Health Professional
Yes
Currently Seeing A Counsellor?
*
Currently Seeing A Counsellor?
No
Currently Seeing A Counsellor?
Yes
Referrer Information
Referrer First Name
*
*
Referrer Last Name
*
*
Referrer Organisation/ Practice/ School Name
*
*
Contact Telephone Number
*
*
Email Address
*
*
Client Details
Forename
*
*
Surname
*
*
DOB
*
*
Gender
Female
Male
Other
Prefer not to say
Non-binary
Address Line 1
*
*
Address Line 2
*
Address Line 3
*
City
*
County
*
Country
*
Postcode
*
*
First Language
BSL
English
Arabic
Bengali
Czech
Danish
Dutch
Finnish
Farsi
French
German
Greek
Hindi
Italian
Japanese
Javanese
Korean
Kurdsh Sorani
Malay
Mandarin Chinese
Marathi
Pashto
Persian
Polish
Portuguese
Punjabi
Romanian
Russian
Slovakian
Spanish
Swedish
Tamil
Telugu
Thai
Turkish
Ukrainian
Urdu
Vietnamese
Wu
Other
Language
*
Additional Information
Additional Needs
Additional Needs
No
Additional Needs
Yes
Special Requirements
Female Therapist Only
Male Therapist Only
Wheelchair Access Required
Learning Disability
Hearing Difficulties
Speaking Difficulties
Visual Difficulties
Other
Additional Needs Details
*
Reason for Referral
*
*
What do you hope to achieve from counselling?
*
Does the client have a mental health diagnosis?
*
Has the client considered or attempted suicide at any time in past 12 months?
*
*
Is the client currently considering suicide?
*
*
How can we contact client to discuss referral?
Mobile/Other Phone
*
*
Can we leave a voicemail?
Can we leave a voicemail?
Don't Allow
Can we leave a voicemail?
Allow
Can we contact by text
Can we contact by text
Don't Allow
Can we contact by text
Allow
Email Address
*
*
Can we contact by Email
Can we contact by Email
Don't Allow
Can we contact by Email
Allow
Medical Information
On a waiting list
*
On a waiting list
No
On a waiting list
Yes
Waiting List Details
*
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