Counselling Service Referral Form

Please fax, email or post completed referral forms to the Counselling Services Manager, Fedja Dalagija, at:

Age UK Camden Tel: 020 7239 0400

Tavis House Fax: 020 7278 1904

1 – 6 Tavistock Square

London

WC1H 9NA

Email:

Client’s Details – PLEASE COMPLETE ALL FIELDS

Title / Male/Female / Tel: mobile
E mail
Forename / Address
Family Name
Date of Birth
Tel: Home / Postcode

Next of Kin or other contact

Title / Male/Female / Tel Home
Tel Mobile
Forename / Address
Family Name
Relationship to Client
Date of Birth/Age / Postcode

GP’s Details

Name
Practice
Address
Postcode
Tel


Reason for Referral

Please indicate briefly why the client is requesting counselling or why you consider it appropriate to refer him or her.

Home Details – WARD LIVED IN ………………………

Type of permanent accommodation / House / Flat/Bedsit / Bed and Breakfast / Supported Housing
Registered Care
Tenure of permanent accommodation / Council / Home Owner / Housing Association / Private rented
With family / Other (specify)

Ethnicity

White / Mixed / Asian or Asian British
White British / White and Black Caribbean / Indian
White Irish / White and Black African / Pakistani
Any other white background / White and Asian / Bangladeshi
Any other mixed background / Any other Asian background
Black or Black British / Other Groups / Other
Caribbean / Chinese / Refusal
African / Any other group not stated (specify)` / Not stated

Communication

Communication
Does the person have any communication
problems such as with language, illiteracy,
hearing or visual impairments? (Please give
details) / Preferred Language
Interpreter
Required? / Yes (tick) / No (tick)


Risk Assessment and Further Information

· Does the client know they are being referred?
· Can contact be made to the client’s home by telephone?
· Is the client a carer?
· Does the client live alone? / Yes/No
Yes/No
Yes/No
Yes/No
If no, please specify who with:
· Is a home visit requested? / Yes/No

NB If the following questions are not answered fully, we may be unable to offer a home visit.

· Self neglect?
· Accidental harm?
· Intentional self-harm?
· Abuse from others?
· Violence/ aggression?
· Environmental hazards?
·  Does the person have pets?
· Any other risk factors / Yes/ No / Unknown / Further Comments
Yes/ No / Unknown
Yes/ No / Unknown
Yes/ No / Unknown *
Yes/ No / Unknown
Yes/ No / Unknown *
Yes/ No *
· * If yes, please state under further comments

·  Has the client been assessed by Social Services? Yes/No

·  If so, are they receiving a care package Yes/No

·  Has an OT assessment been done Yes/No

·  If there is a support plan, please attach it

It is important that people are referred to the Counselling Service with their knowledge and consent. Please confirm that you have discussed this referral with the person concerned by signing below. The Counselling team will contact the client to discuss the referral and make an appointment for an assessment.

Referrer’s Details

Name / Address
Occupation/
Relationship to client
Tel / Postcode
Fax
Signed / Date

All information given is confidential to the Counselling Service.

Please return this form to:-

Counselling Services Manager

Age UK Camden

Tavis House

1 – 6 Tavistock Square

London WC1H 9NA

For further information, or to discuss a referral or any aspect of the work of the Counselling Service, please call our main switchboard on:

020 7239 0400

If you need to speak to the Counselling Services Manger, Fedja Dalagija or Lead counsellor, Sarah Bolton in person and we are unavailable you will be advised of our core telephone advice opening times. Otherwise you may leave a message with the Head Reception on the above number and this will ne emailed to us promptly.


FOR USE BY ORGANISATION RECEIVING THE REFERRAL ONLY

Date received : ……………………………..

Acknowledged Referral: Yes □ No □

Accepted Referral: Yes □ No □

Informed Referrer: □

Allocated on: Allocated to:

:

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