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Refer a Client
Self Referral
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Self Referrals - Create
Self Referrals - Create
All fields marked with an * must be filled
Please complete as much information as you can – sections marked with a * are mandatory and you won’t be able to submit your referral without having completed these.
Are you currently seeing a Mental Health Professional?
*
Are you currently seeing a Mental Health Professional?
No
Are you currently seeing a Mental Health Professional?
Yes
Are you currently seeing a Counsellor?
*
Are you currently seeing a Counsellor?
No
Are you currently seeing a Counsellor?
Yes
Are you accessing our services via an employer or organisation?
Are you accessing our services via an employer or organisation?
No
Are you accessing our services via an employer or organisation?
Yes
If yes, which employer / organisation?
*
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
Do you have any additional needs to help you access our services?
Do you have any additional needs to help you access our services?
No
Do you have any additional needs to help you access our services?
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?
*
How did you hear about us
*
Addictions Service
CAMHS
College/University
CMHT's
Employment Service/Project
Family
Friend
GAMH
GP
Health Practitioner
Housing Association
LGBT
Lifelink Advert
Lifelink Website
Lifelink leaflet etc.
Local Project
Other
Other Agency
PCMHT's
Sandyford
School
Social Work
Used service before
Word of mouth
Work
Youth Health Service
Do you have a mental health diagnosis?
*
Have you considered or attempted suicide at any time in past 12 months?
*
*
Are you currently considering suicide?
*
*
How can we contact you to discuss your 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 you by Text
Can we contact you by Text
Don't Allow
Can we contact you 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
GP Practice
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GP Phone Number
*
Are you on a waiting list for any other mental health or support services at present?
*
Are you on a waiting list for any other mental health or support services at present?
No
Are you on a waiting list for any other mental health or support services at present?
Yes
If yes please say which service/s
*
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