Individuals Counselling Intake and Referral Form

Referral form

2025
Data Protection Statement

Any personal information you give to us will be processed in accordance with the UK Data protection law (GDPR). Heart to Heart Bristol uses your information to process requests for counselling. Anonymised data may also be used for statistical purposes to support funding and service evaluation.
Name*

First NameLast Name
Gender/Preferred pronoun*
Date of Birth *

DayMonthYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Do you work with any other agencies?
(e.g. social worker, mental Health support, other support/counselling ages)Type a question*
Please state your GP details (to be used in an emergency/ If necessary to do so)*

GP NameGP Address

How did you hear about us?*

GoogleLeafletPersonal RecommendationAnother OrganisationGPOther
If 'other' or 'Personal Recommendation' please state*

Hopes and Preferences
What are you hoping might be different as a result of counselling?*
Have you had any previous support or counselling? If so, what stood out to you?*
Is there anything you'd like me to keep in mind about how we work together?*

Emotional and Mental Wellbeing
How have you been feeling in yourself recently?*
Are there particular feelings, thoughts or behaviours you're finding difficult?*
Safety and Wellbeing
Are there any current concerns about your safety or wellbeing?*
Would you like support with any risks or challenges you’re facing?*

Identity and Values
Are there parts of your identity, background or beliefs you'd like considered in our work together?*
Practical Considerations
Is there anything else that might help you feel more at ease in sessions?*
Do you have any additional needs or disabilities that you would like to make us aware of? *

Please tell us if you have previously or currently suffered with any mental Health issues (diagnosed or undiagnosed) including any medication you may be taking at present.*
Please tell us about any health conditions that would make you a risk when having Face to Face sessions or if there anything else you think we should know:*

The following questions are designed to help us understand your situation and make sure we offer you the right support. Please answer as fully as you feel you can.
What is the main reason you are referring to us and how is this affecting your daily life?*
Have you currently or previously suffered with any suicidal thoughts or self-harm? If so, please give details. *
Have you ever planned to act on suicidal thoughts? If so, how recent? *
Please note if you feel you are currently in crisis, we may not be the right service for you and we may recommend other services to support your needs.
What support (if any) has already been put in place for you (home/work for example)?*
Please provide a safe for now contact of someone you are happy for us to contact on your behalf for support if needed, at your request only e.g. A friend/partner. *

NamePhone Number

By signing this form means you agree to the following:*

I agree to this referralI agree to paying the £10 depositI agree to information sharing with agencies when necessaryI agree to secure storage of my personal details
Signature*

Clear
Date*

DayMonthYear
Date
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Referral form