Psychotherapy Referral

Psychotherapy Referral Form
Hello! And welcome to my practice.

Your answers to this form will help us decide if my services are appropriate for your needs, and, if so, will provide a useful starting point for your therapy.

I abide by GDPR regulations; your completed referral form will be stored securely and never shared with third parties (without your explicit written consent).

My working hours are 9am-4pm Mon-Fri. Before you invest time completing this form, I suggest you email me at enquiries@lukehicken.com to check my current availability.

Warm regards,

Luke

Suitability for Online Therapy

Online therapy is appropriate only if attended in a safe, private space with adequate connection and signal.
Can you arrange to be in a private space with your device, with adequate internet connection for video calls, where you won't be interrupted or overheard during sessions?

YesNo
Online therapy is not appropriate unless it's attended in a private space with adequate internet connection. You might consider phone sessions, or sourcing a therapist on the BACP register who works in person.

Contact Details

These details are required in order to contact you regarding appointments, and to get you help in the event of an emergency.
Name*

First Name(s)Last Name(s)
Preferred Name*
What would you like me to call you?
Gender*
Please specify your gender and preferred pronouns
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

City/Town/VillageCounty/State

Postal / Zip Code
General Practitioner (GP) Name
GP Practice Phone Number*
GP Practice Address*

Street Address

General Practitioner (GP) Name

City/Town/VillageCounty/State

Postal/Zip CodeCountry
Emergency Contact*

Emergency Contact Name

Street Address Line 2

Relationship to You Relationship to You

Emergency Contact Phone Number
Emergency Contact Phone Number*

Assessment

Your answers to the following questions will help me assess whether my services are appropriate for your needs, and how I might tailor them to your issues and preferences. Feel free to answer as much or as little as you feel comfortable. It is also perfectly normal to be completely unsure about an answer — feel free to say so.
Issues and Goals
What issues, problems, or ways in which you suffer, have motivated you to seek therapy?
e.g. What feelings, thoughts, motivations, or behaviours are difficult for you? Under what circumstances do these affect you? What sensations occur in your body when these issues are affecting you? Were any of these issues triggered by a particular event? What happened?
What of your personal history might be relevant to the issues for which you are seeking therapy?
e.g. What of your life story feels relevant to the issues you want to address? Do any aspects of your childhood feel relevant? Any past relationships? Family life? Any particular events, losses or other life changes?
If you got everything you wanted from therapy, in what ways would things be different for you?
e.g. Would you feel differently? Think differently? Behave differently? If so, how? And in what situations would you notice these differences? Would your relationships be different? Which ones? How so? Would you have practically changed your circumstances? If so, how?
What do you do, or have, that is already somewhat helpful in coping with the issues you'd like to address in therapy?
e.g. certain relationships, pets, activities, exercise, coping strategies, hobbies, breathing exercises, meditation, medication, clubs, communities, religion, sports, routines.
Please provide anything else you want me to know about the issues or goals you'd like to address in therapy:

If there is anything else you'd like to share, or any feedback you'd like to give about this assessment form, please provide it below:
Should be Empty:

Psychotherapy Referral Form

Suitability for Online Therapy

Online therapy is not appropriate unless it's attended in a private space with adequate internet connection. You might consider phone sessions, or sourcing a therapist on the BACP register who works in person.

Contact Details

Assessment

Issues and Goals

Risk Assessment

Basic Needs

If you are currently in urgent physical danger, please call 999 (UK) to access emergency services.

Relevant Medical Assessment

Self-Harm

If you are currently in urgent physical danger to yourself, please call 999 (UK) to access emergency services.

If you need someone to talk to at any time, a Samaritan is always available to call free at 116 123 (you may like to save that number in your phone).

Your Therapy Preferences