Initial Referral

Initial Referral

CR5
Do not complete this referral if you are seeking mediation. Please use our Client Information Form.

The information you provide below will be submitted using encryption and stored on our secure case management system. It will only be shared with the practitioners that work with you.

To enable us to understand your current situation and ensure we have a suitably qualified and experienced practitioner to offer you an appointment with, we kindly ask that you provide the following information.

Please note that should you be offered an appointment we will require you to complete our client registration form which can be found on our website under Clients/Forms.
Personal Details

This is the person completing the form.
Does the referral relate to:
I am considering the following services

Other
THERAPY REQUEST

We currently have limited availability for therapy sessions on a Monday or Tuesday only.
Your Name

PrefixFirst NameLast Name
Gender
Age
Mobile Number
Personal Email
Subject Information

If you are completing this referral on behalf of another adult or child, please complete the information below.
Name

First NameMiddle NameLast Name
Gender
Age
Relationship to Child
Mobile Number
Email
example@example.com
School/College/University
Local Authority
Please let us know which local authority you pay your council tax to. This is to avoid conflict of interest with certain Educational Psychologists we employ.
Current Situation

Please briefly describe your current situation or the situation of the indivdual concerned.
Current Situation
Please provide a brief description of your current situation and what outcome you are seeking. For example, you are seeking therapy to help reduce your anxiety in social situations or you are seeking a diagnosis to help you better understand yourself.
In the past month I have experienced
Further information Required
If you have selected any of the above options we need a little more information
General Psychological History

Other
General Psychological History Details
As you have indicated in your general history that you have experienced one of the options listed above can you kindly provide us with further details.
Have you received therapy or mental health support in the past three years?
Previous Mental Health Support Details
If you have answered yes to the above question please provide us with further details.
Are you currently taking any medication?
Please tell us the medication you are currently taking
Consent

Please review your form to ensure you have provided the correct information and when you are satisfied, please sign below in the space provided. You may use your finger, stylus or mouse. Once submitted it will be transmitted using encryption to our Case Management Team who will respond within 24 hours.
Whom should we contact regarding this referral?

Other
How should we contact you or the subject named in the referral?

Other
Can we leave a message on your answering phone
I confirm that the information provided above is true and accurate. I am happy and consent to the Practice MK to use the information provided and share with the appropriate employee or associate in order to assess and provide future services to me or the person I named within the referral.
Please provide your signature below
Should be Empty:

Personal Details

Subject Information

Current Situation

Consent