SRFCA - Referral Form

Referring Details
Is the referral for you or someone else?*
In order to continue with this referral please confirm you have permission from the person being referred to make this referral*

I confirm
In order to continue with this referral please confirm that the referred person is NOT currently receiving any mental health therapy*

I confirm
In order to continue with this referral please confirm that the referred person is NOT currently feeling suicidal, engaging in significant self harm behaviours and can keep themself safe*

I confirm
In order to continue with this referral please confirm that the referred person is NOT currently seeking counselling to support a legal case or is court-ordered for therapy*

I confirm
Name of referring organisation*
Name of referring person*
Profession/ Job title of referring person*
Email address of referring person
Contact number of referring person
Personal details
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityPostcode
Gender*
Phone Number*
Can we leave voicemails?

YesNo
Email*
example@example.com
Emergency Contact
Emergency contact name

First NameLast Name
Emergency contact phone number
Relationship to the emergency contact
GP Practice Details
Name of Practice*
Phone Number*
Practice Address*

Street Address

Street Address Line 2

CityPostcode

Postal / Zip Code
Reason for referral
Services you're interested in*

Fully Recovery Pathway1-1 CounsellingGroup TherapyHolistic ServicesDrop in Safe Space
Types of trauma you experienced or witnessed during childhood*

Physical AbuseEmotional AbuseSexual AbuseOther
On a scale of 1 to 10, how much does your trauma impact your life?

1

2

3

4

5

6

7

8

9

10

1 is Not at all, 10 is Everyday
What are your expectations from receiving therapy?
How did you hear about us?*

FacebookTwitterOther social media channelsSearch engineFlyer/ NewsletterWord of mouthGP/ MH Nurse/ Community link workerReferral from another charityOther
Confidentiality and Privacy
We advise you and your organisation to carefully assess each referred person for our therapy to help mitigate any distress or disappointment. We treat inquiries and counselling discussions as private and confidential. Any information provided will be kept confidential. Information will not be disclosed to anyone outside the charity unless expressly requested in writing. However, in rare cases, we reserve the right to breach confidentiality if there is a credible risk of harm. Respecting your confidentiality and privacy is fundamental to our service. Your form will be encrypted and stored securely in our password protected system and governed by strict GDPR rules. We will not share your information with anyone outside our organisations, unless we believe you are at imminent risk of harm (or a child or vulnerable adult is at a serious risk). In this instance we are legally bound to share basic information in order to keep you (or a vulnerable other) safe.
I have read and I understand this privacy information*

Yes
Should be Empty:

Referring Details

Personal details

Emergency Contact

GP Practice Details

Reason for referral

Confidentiality and Privacy