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> Make A Counselling Referral
Cithrah Referral Form
Please complete the following form to make a referral
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Title
Miss
Ms
Mrs
Mx
Mr
Dr
Prof
First Name
*
Surname
*
Email
*
Email
Confirm Email
Contact Number
*
Address (House Number & Street)
*
Town/City
County
Country
Postcode
*
Date of Birth (DD/MM/YYY)
*
Gender
*
— Select Choice —
Male
Female
Transgender
Non-Binary
Prefer to Self Describe
Not Disclosed
Parent/Guardian (If under 18 enter name & contact number)
Current School
Referral Source
*
— Select Choice —
Friend
School
GP
Self-Referral
Other
Referred By
What support is required?
*
Have you had counselling with us before?
*
How did you hear about us?
When are you available? (please state availability between Mon-Fri, 9.00 – 5.00)
*
GP Name and Address
*
Medication (please provide details including dosage)
Additional Information ( please provide any additional information you may feel is relevant including any involvement with other mental health services)
Do you require any special requirements or access arrangements? (If yes, please state)
provide name under
Family Member Details
Title
Miss
Ms
Mrs
Mx
Mr
Dr
Prof
First Name
*
Surname
*
Email
*
Email
Confirm Email
Contact Number
*
Address (House Number & Street))
*
Town/City
County
Country
Postcode
*
Date of Birth (DD/MM/YYY)
*
Gender
*
— Select Choice —
Male
Female
Transgender
Non-Binary
Prefer to Self Describe
Not Disclosed
Relationship
Mother
Father
Legal Guardian
Other
How we use client information
We may use client information to carry out our obligations arising from any contracts entered into by the client and us. We promise to keep your details safe and secure. We will not share your information with third parties for marketing purposes. We may contact you to let you know about other services, events or for evaluation purposes. The circumstances when details can be shared include:
• When a counsellor has good grounds for believing that a person may cause serious harm to themselves or others.
• When we are instructed by a court to disclose information.
• When a person discloses criminal activity, or knowledge of criminal activity, this includes statutory obligations.
• When it is necessary to uphold child protection laws.
Your responsibility
We would ask that you keep us informed (by email, telephone, or in writing) of any changes in your personal data so that we may have our records up to date at all times. If you wish to withdraw your consent please contact us (by email, telephone, or in writing). You have the ‘right to be forgotten’, which means you can request the deletion or removal of personal data where there is no compelling reason for its continued processing.
GP/3rd Party Consents
*
I consent
I consent that you can share details with my GP and other 3ʳᵈ parties who are involved in the contract entered into by you and us
Communication Consents
*
I consent that I’d like to hear from you via email
I consent that I’d like to receive phone calls from you and you can leave voice messages
I consent that I’d like to receive SMS texts from you
I consent that I’d like to receive letters from you
Tick your preferred methods of consent from the list above. Please TICK ALL that apply (a minimum of one must be selected)
Consent Confirmation
*
I consent
By ticking this box you understand you have given your consent for us to use your information in case of emergency.
Submit
