Counselling Portsmouth - Client Self-Referral Form

Personal Details
First Name: / Surname:
Phone number:
Can we leave a voicemail? Yes / No
Can we text an appointment reminder? Yes / No / Email:
Address:
Postcode: / Date of Birth:
Equality Monitoring
This information helps us monitor whether the service is reaching all groups within the community. Please put a cross next to thegroup or leave blank if you prefer not to say.
Gender:
Male
Female
Transgender / Sexual Orientation:
Heterosexual
Gay / Lesbian
Bisexual
Ethnic Group
White
English / Welsh / Scottish / Northern Irish / British
Irish
Gypsy or Irish Traveller
Any other White background
Mixed / Multiple ethnic groups
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / Multiple ethnic background
Asian / Asian British
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
Black / African / Caribbean / Black British
African
Caribbean
Any other Black / African / Caribbean background
Other ethnic group
Arab
Any other ethnic group
Do you consider yourself to have a disability?
Yes / No
Please describe any special requirements we need to be aware of in order for you to access counselling
Reason for Referral
Please put a cross next to the main issue(s)that brings you to counselling.
Your counsellor will discuss the situation in more detail with you at the first meeting.
Abuse / Family issues
Addiction / Gender / Sexuality
Anger / Mental Health
Anxiety / Physical Illness / Feeling unwell
Bereavement / Loss / Relationship issues
Crime / Self-Confidence
Debt / Finances / Self-Harm
Depression / Trauma
Domestic abuse / Welfare / Homelessness
Work issues
Medical Details
We will not disclose to your GP that you are having counselling. Your GP would only be contacted if we believed we needed to take direct action due to a risk to your health. We would make every effort to support you to speak to your GP yourself first.
Doctor's Name:
Practice:
Address:
Postcode:
Have you received any mental health diagnosis from your GP or any other mental health professional?
Yes/No
If yes, please give details:
Are you currently receiving any psychological therapy, counselling or mental health support from any other mental health professional (e.g. psychiatrist, psychologist, CPN)? Yes/No
If yes, please give details:
Please let us know if you have experienced any of the following problems in the last month:
Thoughts of ending your life / Self-harm
Taking steps to end your life / Harm from another person
Harm related to drugs or alcohol
Are you currently on any medication? Yes/No
If yes, please give details:
Session Times
The counselling service is currently open at the following times. Please select all the possible times you could attend.
The sessions are 50 minutes and will usually be weekly at the same time.
10am / 11am / 12pm / 1pm / 2pm / 3pm / 4pm / 5pm / 6pm / 7pm
Mon
Tues
Weds
Thurs
Fri
Income Details
We aim to provide an affordable service which benefits the community. Our fees are means-tested according to benefits and income. Please select your fee level and bring supporting documents to your first meeting.
Receiving basic benefits only (Universal Credit, Income Support, JSA, ESA) / Fee: £5 per session
Full time students / Fee: £5 per session
Receiving enhanced benefits (as above plus allowances such as Carer’s Allowance, PIP) / Fee: £8 per session
Employed, income under £20,000 per year / Fee: £10 per session
Employed, income £20,000-£25,000 per year / Fee: £15 per session
Employed, income £25,000-£30,000 per year / Fee: £20 per session
Employed, income over £30,000 per year / Fee: £25 per session
I consent to the information I have provided being processed by Counselling Portsmouth
Signature: / Date:

A copy of the YOU Trust’s Data Protection Policy can be provided on request.

Please email completed referral forms to our secure email address:

The YOU Trust LTD (Registered Charity – 291489)

South Wing, Admiral House, 43 High Street,

Fareham, Hants, PO16 7BQ