Adult

If you are making a referral for someone else (over 18) we need some information about you

Your name (Referer):

Your address:

Your email:

Your mobile number

Your relationship to the person being referred for support

Are you the next of kin (if not please provide next of kin details below)

Yes

Next of kin will only be contacted in case of an emergency

Next Of Kin Details (if not already provided)

Name (Next of Kin)(Required)

Address (Next of Kin)(Required)

Email (Next of Kin)(Required)

Mobile Number (Next of Kin)(Required)

Relationship (Next of Kin)(Required)

Details of the person requiring support:

Name (Client)(Required)

Address(Required)

Postcode(Required)

Mobile Number(Required)

Can we leave a message?(Required)

Yes

Can we sent a text?(Required)

Yes

Date of birth (dd/mm/yyyy)(Required)

DD slash MM slash YYYY

Gender(Required)

Male

Female

GP Name(Required)

GP Practice name, address and telephone number(Required)

Reason for Referral

Please describe some of the concerns that have led you to seek support now. Please see our FAQs for details on what is/is not considered an appropriate referral for our service.

Additional Information:

Are you currently receiving support from any NHS mental health services or private therapists (including, adult mental health, counselling, psychological services, psychiatry, addiction services etc)

Are you currently receiving support from any NHS mental health services or private therapists (including, adult mental health, counselling, psychological services, psychiatry, addiction services etc)

Yes

If yes, please give brief details of the service(s) you are currently receiving support from and the nature of the difficulties being experienced.

If yes, please give brief details of the service(s) you are currently receiving support from and the nature of the difficulties being experienced.

In the past have you previously accessed any NHS mental health services or private therapists (including, adult mental health, counselling, psychological services, psychiatry, addiction services etc)

In the past have you previously accessed any NHS mental health services or private therapists (including, adult mental health, counselling, psychological services, psychiatry, addiction services etc)

Yes

If yes, please provide brief details of when this was, the type of service used and the nature of the difficulties at that time.

Your current emotional wellbeing:

Do you currently have any concerns about your ability to keep yourself safe e.g. thoughts or plans of suicide or self harm?

Yes

Do you, or someone in your family, think alcohol is a significant problem for you?

Yes

Are you currently using recreational drugs or misusing any prescription medication?

Yes

If you have any concerns about safety (your own or others) please contact your GP, Out of Hours GP, Lifeline NI (24/7) crisis helpline, 0808 808 8000 (deaf and hard of hearing Textphone users can call Lifeline on 18001 0808 808 8000).

Payment

How do you wish to pay:

I am paying for sessions myself

I have private health insurance

If you have private health insurance please provide the following information. We will not be able to progress with your referral until this information is provided:

Name of your Private Health Insurance (PHI) Provider:

PHI Policy Number

PHI Authorisation Code

*Please note, our practice is not registered with all UK wide PHI providers but we will advise you if this affects your referral before proceeding.

Consent

I consent to the information in this form being used for the purposes of clinical decision making regarding suitability for this service.

I confirm that the person I am referring is aware that this referral is being made and I have their permission to provide information about them (including about their health) for the purposes of determining their suitability for this service.

GDPR

We will not share your information with anyone outside our practice, unless we believe you, or someone else is at imminent risk of harm. In this instance we are legally bound to share information in order to keep you or others safe.

I hereby agree that the data entered in this referral form will be stored electronically and will be processed and used for the purpose of establishing contact. I am aware that I can revoke my consent at any time.

I confirm I have read and agree to the above statements regarding consent and GDPR