REMOTE SERVICES FOR COUNSELLING Self-Referral

Nelson House

Bergen Way

North Lynn Industrial Estate

King’s Lynn

PE30 2DE

tel: 01553 770770

www.onetooneproject.com
REMOTE SERVICES FOR COUNSELLING

Self-Referral Form
Use this form if you would like to request a service for yourself. (Please complete all boxes)
Where did you hear about our services?
Your Details
Name
Date of Birth

DayMonthYear
Date
Address
MaleFemaleOther
Post Code
How We Contact You?
Landline Number
Please provide all contact details and state your preferred method of contact
Mobile Number
Email Address
Please tick if you give permission for us to contact you:

By EmailBy PostBy PhoneBy Mobile Phone
Your GP's Details
GP Name:
Prescribed Medication:
Practice Address:
Practice Tel No:
Are you currently receiving support from another service? (e.g. psychological/psychiatric services)
Please provide information about any past support from Mental Health Services
About You
What are your current difficulties?
Have you had any thoughts of suicide in the last three months?

YesNo
If yes, please give details: (Please note that the One to One Project is not a crisis service. In the event of current thoughts of suicide, please contact Samaritans on 116 123 or the Crisis Team on 0300 790 0371 if you are already a Trust user)
Thoughts of Suicide Details
Do you have any difficulties with alcohol and/or non-prescribed drugs?

YesNo
Details of drug/alcohol difficulties
What would you like to achieve with the support of the One to One Project?
Which remote service do you require?

Counselling via ZoomTelephone Counselling
Please outline any specific needs which we may have to be aware of:
Language?
Cultural?
Access?
Disability?
Other?
How would you like your counselling delivered?

Face-to-faceTelephoneZoomOutreach Hub
Signature

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Date

DayMonthYear
Date
Your Name
Should be Empty:

REMOTE SERVICES FOR COUNSELLING

Your Details

How We Contact You?

Your GP's Details

About You

Please outline any specific needs which we may have to be aware of: