Updated Nov 2016

Lifecentre Face to Face Counselling and Play Therapy

Referral Form -External Agencies

Lifecentre offers:

  • Face to face counselling for survivors of all types of sexual violation and their supporters (incl. rape and childhood sexual abuse) for men and women and children. Counselling available in Chichester, Worthing and Crawley. Adult clients are asked to consider making a donation towards the cost of their counselling according to their means.
  • Telephone Helpline: Sunday, Monday, Tuesday, & Thursday evenings 7.30pm – 10pm.

Free phone:0808 8020808 Text helpline: 07717 989 022

For Data Protection reasons please do not include on this page any information of a sensitive nature.

Reason for referral(must include some form of sexual abuse):
If you are referring a child under the age of 18 years, has their sexual abuse been reported to MASH? Yes/No Who reported? When?
Have the police had any involvement?
Is there any likelihood of a court case , or state ‘not known’
Has there been any contact with Adults or Children’s Services?
Medical History
*Please ensure all questions are answered below, to avoid delays in processing
Does this person have any history of mental health problems? Yes/No
Please provide details including any diagnosis and dates where known.
Has the person ever been prescribed medication for mental health issues? Yes/No
If yes, please give details of medication and dosage and dates where known.
Please advise of any professionals involved in this person’s care e.g. From the Mental Health Team/Substance misuse service etc.?
Name of professional/s involved and agency:
Has this client ever been suicidal? Was this suicidal thoughts only? Yes / No How long ago?
Suicide attempts? Yes/ No If so, what did they do and when was this? How many attempts?
If client has been recently suicidal do they have any current ongoing support professional or personal to stabilise them?
Are there any significant physical health challenges or disabilities, e.g. Epilepsy / wheelchair user?
Additional information:
Any requests from Referrer:

For more information feel free to phone our office line on 01243 786349.

Please return this form to:
Notes – Office Use only

Unlockingthepast•Survivingthepresent•Reclaimingthefuture

Free phonehelplinesupport:

Tel: 0808 802 0808 • Email: • Text: 07717 989 022

Life Centre, charity number 1127779, a company limited by guarantee, registered in England number 6766164. Registered office: 1-2 St Pancras, Chichester West Sussex PO19 7SJ • Lifecentre works to a Safeguarding Children policy