NCG Counselling Referral Form
Client Details
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: 00000000000.
Email
*
Date of Birth
*
/
Day
/
Month
Year
Date
Address
*
Street Address
Street Address Line 2
City
Borough
Postal / Zip Code
Gender
*
Please Select
Male
Female
Other (please specify below)
Other: (please specify gender)
Nationality
*
Languages Spoken:
*
Immigration Status
*
Please Select
Asylum Seeker
Refugee
Marital Status
*
Please Select
Married
Civil Partnership
Single
Divorced
Widowed
Back
Next
GP Details
Name of GP & GP Surgery
*
GP Phone Number
*
Please enter a valid phone number.
Format: 00000000000.
Email
*
Address
*
Street Address
Street Address Line 2
City
Borough
Postal / Zip Code
Back
Next
Client's Health Summary
Medication
*
Physical Health
*
Diagnosis (if any)
Back
Next
Reason for the Referral
Summary of presenting problem(s):
*
Does the client have any history of (i) violence (ii) self-harm (iii) eating disorders (iv) other?
*
Back
Next
Referrer Details
Tick the box if you are self-referring
Full Name of the Referrer
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: 00000000000.
Date of Referral
*
/
Day
/
Month
Year
Date
Relationship to the client:
Organisation
*
Please Select
Self-Referral
Organisational Referral
Please specify Organisation:
Declaration:
*
I confirm that the client is aware of this referral, and he/she/they are happy for New Citizens’ Gateway (formerly Barnet Refuge Service) to contact them directly.
Signature
*
Submit
Should be Empty: