Lifft Wellbeing - Referral Form

Counselling Referral Form

CONFIDENTIAL
To begin the counselling process please complete and return this Referral Form

Currently our counselling service is available online or by telephone or face to face

Once we have received your completed referral form we will contact you to arrange an assessment whether our service is the best fit for your needs, if we are then we will discuss the optimum therapeutic approach and available sessions times.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Postcode
Email Address*
Preferred Contact Number*
Please enter a valid phone number.
Alternate Contact Number
Please enter a valid phone number.
Let us know if there any contact restrictions / issues that we should be aware of
Gender

FemaleMalePrefer Not to SaySelect to Self Describe...
Ethnicity

Choose one of the below ethnicities that you feel best describes you
White

Welsh, English, Scottish, Northern Irish or BritishIrishGypsy or Irish TravellerAny other White background
Mixed or Mutiple ethnic groups

White or Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed or Multiple ethnic background
Asian or Asian British

IndianPakistaniBangladeshiChineseAny other Asian background
Black, African, Caribbean or Black British

AfricanCaribbeanAny other Black, African or Caribbean background
Other ethnic group

ArabAny other ethnic group
Next of Kin Name

First NameLast Name
Next of Kin Address

Street Address

Street Address Line 2

CityCounty

Postcode
Next of Kin Phone Number
Please enter a valid phone number.
Name of GP

First NameLast Name
GP Address

Surgery Name

Street Address

CityCounty

Postcode
GP Phone Number
Please enter a valid phone number.
Name of NHS Mental Health Service Contact / Social Worker

First NameLast Name
NHS Department
Phone Number
Please enter a valid phone number.
If you are completing this referral form for someone else please complete your contact details below. To proceed we will need the person to sign this form to give their consent.
Referrer Name

First NameLast Name
Referrer Organisation
Referrer Contact Number

Area CodePhone Number
Any additional information that, as the referrer, you feel is relevant
What is the issue that you are seeking counselling for?*
What are you hoping your counselling achieves?
Are you taking and prescribed medication? If Yes, please list below
Have you had any thoughts of harming yourself or others? If yes please provide more details
Is there anything else you think we should know / be aware of?
Please select any of the below that you are experiencing

AnxietyAnxiety / Panic AttackAngerAcademic DifficultiesBereavement / LossBody DysmorphiaBullyingDepressionDomestic ViolenceEating IssuesEmotional AbuseFamily DifficultiesFamily Separation / DivorceFinancial DifficultiesObsessive / Compulsive IssuesPhobia/sPhysical Health Issue/sPhysical AbusePost Traumatic StressRelationship DifficultiesSelf-HarmSelf Worth / Self EsteemSexual Abuse / AssaultSexual Identity IssuesSleeping DifficultiesStressSuicidal ThoughtsSubstance Abuse / AddictionsTrauma
How did you hear about Lifft Wellbeing CIC

GoogleTwitterLinkedInFacebookWord of MouthCounselling DirectoryOther
Thank you for completing this form

How to return to us -

Email: Info@lifft.Org

or

Post: Lifft Wellbeing CIC, Garn Farm, Wenvoe, Cardiff, CF5 6BE

Once we receive your form we will contact you within 3 working days to book your assessment.

By completing this form you acknowledge and accept that Lifft Wellbeing CIC will hold and process in accordance with GDPR your personal data as necessary to provide our counselling service.
Signature*

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Counselling Referral Form