Counselling and Bereavement Service Referral Form

Counselling and Bereavement Service Referral Form

For people (16+) in need of BEREAVEMENT SUPPORTORACCREDITED COUNSELLING(AQP)via accredited IAPT Trainedcounsellors

Patient Name: / NHS No.
Mr/Mrs/Ms /Miss
(Please Circle) / DOB
Ethnicity
Patient Address:
Postcode: / Email
Address:
BEST Contact No: / GP Name:
GP Address:
GP Email:

Relevant Medical and Mental Health History:

Reason for Referral:

Options available

ACCREDITED COUNSELLING 1-1 sessions.

Please Tick

Bereavement Support see Overleaf:

Please state number

Referred by (PRINT Name and Organisation): Date

Adult Counselling and Bereavement Service

Peace Hospice Care offers a wide variety of supportive interventions for those who are bereaved in addition to the 1:1 counselling service. Whilst many are referred via their GP’s, we will accept external referrals from individuals and other health care providers working in Hertfordshire.

No / Service / Target Audience / Additional information
1 / Accredited Counsellors providing 1:1 support / People requiring counselling to support adaption and life style changes in order to foster a sense of health and well being / CCG funded service. Counsellors have AQP Status and offer ‘time limited’ counselling / IAPT – usually 6-10 sessions. Counsellors will do home visits where people are unable to leave their homes
2 / Pre – bereavement / Clients known to the hospice who need support in coming to terms with their diagnosis or members of their family who need help / Starlight Services provide a range of rehabilitation and wellbeing services including day care, meditation, creative therapy, counselling, social work and workshops, for patients with long term conditions
3 / DOVES – once a month lunch club providing Informal support / Those who have recently experienced bereavement following the death of a partner / The group meets on the third Tuesday of the month at– the Toby Carvery, Aldenham Road Roundabout. A group of qualified volunteers are present.
4 / In house group support / This can be interim support whilst waiting for 1:1 counselling or for those requiring additional support after time limited sessions cease / This group meets at the Peace hospice on the third Thursday of the month at 7pm. Group members vary in ages and experiences but have all suffered a bereavement and are supported by Team Leader
5 / Telephone Support Service / The team offer initial contact to those referred to the Service. / The team signpost clients to the services available, identify client preference and/ or maintain contact until 1:1 counselling starts.
6 / Befriending Service / Those who would like a support visit at home but do not require counselling / A team of volunteers whovisit bereaved peoplein their own homes.

Please return completed forms to:

Email:

Fax:01923 233561