Referral Form
St Vincent’s Counselling Service accepts self-referrals, professional referrals, and internal St Vincent’s referrals.If you are having difficulty completing this form, please contact us on 07979 109 077 or email wellbeingreferrals@svp.org.uk and a member of the team will be happy to support you.Please note that submitting a referral does not guarantee counselling support. All referrals are screened for suitability within our low-risk, trainee-led counselling service.If you are in immediate danger or crisis, please contact 999, NHS 111, your GP, or local crisis services rather than completing this form.
Date of Referral
-
Month
-
Day
Year
Date
Which type of referral are you making?
Internal St Vincent's referral
External professional referral
Self-referral
About the person completing this form. If you are having difficulty completing this form online, please ring us on 07979 109 077 and we can support you with the referral.
Are you making this referral for yourself?
Yes
No
Referring Organisation (external professional or internal referral.)
Name of Referrer
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
About the Person Requiring Counselling
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Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Date of Birth
-
Month
-
Day
Year
Date
Age
Phone Number
Please enter a valid phone number.
Format: (000) 000-00000.
Email
example@example.com
How would you like to be contacted (Tick all that apply)
Telephone
Text
Email
May we leave a voicemail?
Yes
No
Gender (optional)
Male
Female
Non-binary
Prefer not to say
Other
Ethnicity (optional)
Prefer not to say
Asian / Asian British
Black / Black British
Mixed / mixed ethnic backgrounds
White
Arab
Other ethnic backgrounds
Next of Kin / Emergency Contact Details
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Next of Kin name
First Name
Last Name
Next of Kin Telephone
Please enter a valid phone number.
Format: (000) 000-00000.
Relationship to Next of Kin
Do we have permission to contact this person if we are concerned about your immediate safety?
No
Yes
Details of Risk (Organisation referrals only)
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Please choose the level risk of self-harm
High
Medium
Low
GP Details
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Surgery Name
Surgery Address (if known)
Street Address
Street Address Line 2
City
GP Practitioner Name (if known)
Reason for Referral
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Please describe the presenting problem (Please give us a brief idea of what has brought you to counselling at this time. )
Please outline previous history of mental wellbeing problems (Have you received any previous support for your mental health or emotional wellbeing? This may include counselling, therapy, GP support, medication, or mental health services.)
Please include any client additional needs (Please tell us about any additional needs or support requirements we should be aware of. This may include disability, neurodivergence, interpreter needs, accessibility requirements, cultural or religious considerations)
Is there anything currently causing significant distress or risk of harm to yourself or other people? Examples may include suicidal thoughts, self-harm, harm to others, legal proceedings, alcohol/drug use, severe eating disorder, or severe mental health difficulties.
How did you hear about us?
GP
Social Prescriber
St Vincent's Staff Member
Friend/Family
Website
Other organisation
Other
CONSENT - Please confirm you consent to us processing and storing your personal data in line with our Privacy Notice, in order to progress your referral into the service.
Yes
No
I understand submitting this form does not guarantee counselling support
I understand St Vincent's Counselling Service is a low-risk, trainee-led service and referrals are assessed for suitability
I confirm the information I have provided is accurate to the best of my knowledge
Submit
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