Counselling Service Referral/Registration Form Type of Issues

Counselling Service Referral/Registration Form Type of Issues

Clients Name:
Name of Project: Counselling
Address
Post code: / Borough
1. Bethnal Green/ Globe Town
2. Bow and Poplar
3. Isle of Dogs
4. Stepney and Wapping
5. Out of Borough
Tele No. Home: / Mobile/other:
Email:
Date of Birth: / Age: / Gender: / Ethnicity:
Do you have a Care Coordinator
Have you ever been diagnosed with a mental health condition/disorder?
If yes, what was the diagnosis given? / No/Yes
No/yes / If no were you discharged from cpa in last 12 weeks / Yes /No
Have you been assessed for personalised budget? / No/Yes / If yes are you in receipt of funding? / If No would you like information about your possible eligibility?
Name and address of GP:
Telephone: / Name & address of care coordinator:
Telephone:
Details of referring agency:
Name:
Role:
Address:
Tele contact number: / Next of Kin Name: No
Relationship:
Address:
Tele contact number:
Presenting Issues/Brief Reason for Referral: / Other Services:
Please detail other agencies/services you are currently linked/involved with
Signed: / Dated:

Counselling Service Referral/Registration form Type of issues

Please put a tick next to the main issues needing support through counselling

Psychological Health / Events
P1 / Depression / E1 / Moving home/homelessness
P2 / Post natal Depression / E2 / Long term imprisonment /institutional care
P3 / Suicidal Thoughts / E3 / Debt
P4 / Self Harm / E4 / Rape
P5 / Post traumatic Stress Disorder / E5 / Burglary
P6 / Anxiety Symptoms/phobias / E6 / Physical Assault
P7 / Panic Attacks / E7 / Neighbourhood disputes
P8 / Hearing voices/psychosis / E8 / Employment: bullying/harassment
P9 / Drug/alcohol problems / E9 / Employment: racial/sexual harassment
P10 / Anorexia / E10 / Employment: Off sick
P11 / Bulimia / E11 / Employment: Redundancy
P12 / Compulsive over eating / E12 / Employment: Difficulties returning to work
P13 / Anger difficulties / E13 / Employment: relationships
P14 / Chronic Fatigue /ME
P15 / Irritable bowel symptoms / Relationship
P16 / Skin complaints / R1 / Bereavement/Grieving
P17 / Obsessive Compulsive symptoms / R2 / Divorce/relationship breakdown
P18 / Midlife crisis / R3 / Partnership (husband /wife issues)
P19 / Low support (food, sleep, interests activities) / R4 / Family issues
P20 / Manic Depression / R5 / Relative’s/partners illness
P21 / Low Self esteem / R6 / Caring role
P22 / Paranoid thinking / R7 / Social relationships
R8 / Social isolation
R9 / Childhood sexual abuse
C1 / Personality Disorder / R10 / Childhood physical abuse
C2 / Ex-offender / R11 / Sexual identity
C3 / High Risk of suicide / R12 / Sexual dysfunction
C4 / Psychoses / R13 / Domestic abuse
C5 / LGBT / R14 / Childhood emotional abuse
Physical Health / R15 / Childhood neglect
H1 / Physical ill health
H2 / Pain management
H3 / Accident resulting in injury/trauma
H4 / Khat use

Once you have completed this form, please email it to:

For any further queries, please contact the Counselling Team on:

020 7510 1081

For staff use only:

Refer Date / Assessor
Assess Date
Start Date
Name
Gender / 1 Male / Age / DoB
2 Female
3 Transgender
Referrer / 1. CMHT / Locality / 1. Bethnal Green/ Globe Town
2. Bow and Poplar
3. Isle of Dogs
4. Stepney and Wapping
5. Out of Borough
Specify: Tower Hamlets
2. Nurse
3. GP
4. Other Vol Sector (specify)
5. Other professional(specify)
6. Mind
7 Self Referral
8 Other (specify)
Specify: / Post Code
Disability or special needs (other than mental health) / CPA Level / 1 Yes
1. Learning Disability / 4 Sensory Impairment / 2. No
2. Long term conditions / 5. Other
Please specify
3. Physical Disability / 6 Not Answered
Ethnic Group / Current contact with MH Services
Asian/BritishIndian / Chinese / 1 / In patient
Asian/BritishPakistani / Vietnamese / 2 / CMHT
Asian/BritishBangladeshi / Other / 3 / None
Other Asian Background / 4 / Other (please specify)
Black/BritishSomali
Black/BritishAfrican
Black/British Caribbean / Sexual Orientation
Black/BritishOther / 1 / Bisexual
Black/British Other African / 2 / Gay
Mixed White and Asian / 3 / Heterosexual
Mixed White and Caribbean / 4 / Lesbian
Other Mixed Backgrounds / 5 / Did not wish to disclose
White British
White Irish / Religion/belief
Other White / 1 / Buddhist / 5 / Muslim
2 / Christian / 6 / Sikh
3 / Hindu / 7 / No religion
4 / Jewish / 8 / Other (specify)
9 / Did not wish to disclose
Issues: / 1.
2.
3.
2. / Priority -
counselling service only / Contact
1.
1st contact
List top 3 reasons for referral / 1-H
2-M
3-L / 2. Subsequent