Please Complete This Form and Email Or Post It To

Self-Referral Form

Please complete this form and email or post it to:

Leeds Mind Group Therapy, Clarence House, 11 Clarence Road, Horsforth, LS18 4LB

Group Therapy at Leeds Mind offers a confidential, safeand supportive space in which to explore emotional and relationship issues that are having an impact on your life. It is a place where you can find ways of responding and relating differently to the people and world around you.By sharing with others, Group Therapy can help you to know yourself better and to make changes in your life.

Therapy in a group works best when members feel free to say what is on their minds. This process develops over time, and group therapy often proves to be a longer-term therapy for issues that havebeen longstanding in nature.

Our therapy group meets for 90 minutes on Thursday afternoons at Clarence House between 2.30 and 4.00 pm. The group meets weekly with the exception of breaks that follow the Leeds School Calendar. There are 40 sessions every year. The length of time that each person belongs to the group is a matter of individual choice, and, as a rule, the group aims to contain between five and eight group members. The group therapist is Ian Fairley.

After receiving your form Ian willcontact you to discuss meeting for an assessment appointment.

Name
Date of Birth / Male/Female/
Transgender
Address
Town/City
Post Code
Telephone
Permission to leave messages?
Email address
GP Practice
What are your main reasons for seeking group therapy?
What issues would you like to explore in the group?
What do you hope to achieve from being in the group ?
Please tell us of any previous therapeutic experiences, and describe how they were helpful or unhelpful to you.

TERMS AND CONDITIONS

The Group Therapistworks within the Ethical Framework of the British Association for Counselling and Psychotherapy, and is responsible to Leeds Mind’s policies and procedures.Copies of Mind’s policies on confidentiality, onchild and adult safeguarding, and of our complaints procedure, areavailable on request. The Group Therapist receives regular clinical supervision of his work.

Group Therapy is a deliberately undertaken activity and relationship requiring your commitment as well as that of the therapist. By signing this form you agree to the following terms and conditions:

You will have at least one 60 minute assessment before beginning Group Therapy. This is an opportunity to learn if this kind of therapy is right for you and to think about what you want from it. The assessment will be charged at the same rate as group attendance. We may ask you to attend during working hours.
For Group Therapy to be effective you need to make a serious commitment to attending sessions.We ask for payment for each session, including missed sessions, as part of this commitment. Leeds Mind operates a sliding scale fee structure depending on income (see below), and we reserve the right to ask for proof of income to ascertain the correct fee band for you.
We ask you to respect that meetings will begin and end on time, to inform us of planned absences, and to consent to being contacted in the event of unnotified absences.
Leeds Mind will not tolerate any form of abuse towards clients or therapists, and reserves the right to discontinue your sessions if this policy is not respected. If we believe you to be under the influence of alcohol or drugs when attending a group, you will be asked to leave for that week.

Fee Band / Criteria
£5 / Available to those who are unwaged or whose income is £8,000 or less
£10 / Available to those whose income is between £8,001 and £16,000
£15 / Available to those whose income is between £16,001 and £25,000
£20 / Available to those whose income is £25,001 or above

GROUP THERAPY FEE SCALE

I confirm that I have read, understood and agree to the terms and conditions for Group Therapy, and agree to pay the following weekly amount to Leeds Mind:

Amount:______

Print Name:______Date:______

Signature:______

If you have problems with any aspect of our service please contact Leeds Mind’s Operations Director who will try to resolve any issues or complaints to your satisfaction.

Please now complete the Diversity Monitoring Form overleaf.

DIVERSITY MONITORING

Giving answers to these questions is at your discretion, and your ability to access the Group Therapy Service is not affected if you choose not to answer them. The information provided here helpsLeeds Mind to monitor and demonstrate the range of people who use its services.

How do you describe your ethnicity? Please tick one box.

WHITE / ASIAN/BRITISH ASIAN
British / Bangladeshi
Irish / Chinese
Other – please state: . / Indian
BLACK / Kashmiri
African / Pakistani
Caribbean / Other – please state: .
Other – please state: .
MIXED / OTHER ETHNIC GROUP
White and Asian / Please state: .
White and Black African
White and Black Caribbean
Other – please state: .

How do you describe your sexual orientation? Please tick one box.

Heterosexual / Bisexual
Lesbian / Other – please state: .
Gay / Do not want to say

Do you consider yourself to be disabled? Please tick one box.

Yes / Do not want to say
No

How do you describe your religion? Please tick one box.

Buddhist / Sikh
Christian / None
Hindu / Other – please state: .
Jewish / Do not want to say
Muslim

How do you describe your relationship status?

Civil Partnership / Single
Co-habiting / Other – please state: .
Married / Do not want to say

How do you describe your residency status?

British Citizen / Asylum Seeker
EU National / Foreign Student
Refugee / Destitute
Do not want to say / Other – please state: .

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