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Adult Referral Form - Step 1 of 5

Adult Referral Form

Please note this form is for Adults over the age of 18 years.

Which Counselling service would you like to refer to? *

General Counselling
Anger Management
Couples Counselling

Your Details

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First Name *

Last Name *

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Date of Birth *

Home phone number

Contact Number

Email

Mobile phone number *

Your Partners Details

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Partner's First Name *

Partner's Last Name *

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Partner's Date of Birth *

Partner's Contact Number

Partner's Email

Please check if you give us permission to: *

Leave messages on your home phone
Leave messages on your mobile phone
Text you on your mobile phone
Send you a message by email

Address

Post Code

Do you have a preference for a male or female counsellor?

Male
Female
No preference

Would you require a ground floor room for your appointments? (For example, due to physical disability).

Yes
No

Do you have any communication or accessibility needs which would affect your ability to access counselling?

Yes
No

If 'yes', please give brief details.

Your emergency contact details

Name

Phone

Alternative phone number

Address

Relationship to you

Please provide us with your GP Details

Surgery

Telephone

Your reasons for seeking counselling

Please give a brief outline of your main reason for seeking counselling

What are the three most important aims you have for your counselling?

Aim 1

Aim 2

Aim 3

Diversity monitoring form

The information you provide in this form is very useful to use in terms of demonstrating who is using the service and monitoring its effectiveness. The information is kept completely confidential and will never be shared with anyone outside of the service.

If you would prefer not to share any information with Rotherham and Barnsley Mind please select the 'prefer not to say' option as appropriate.

Gender

Gender - Other

Ethnicity

Do you consider yourself to have a disability?

Sexual Orientation

Sexual Orientation - Other

Marital/relationship status

Have you been diagnosed with an Autistic Spectrum Condition (ASC)?

Religion

Religion - Other

Residency/immigration status

Residency/immigration status - Other

Where did you hear about Rotherham & Barnsley Mind? *

Terms and conditions

Counselling is a deliberately undertaken activity and relationship requiring your commitment as well as that of your counsellor. As such, please read carefully the following terms and conditions which lay out what we expect from you and what you can expect from us in relation to your time in the service. By ticking the box below you agree to these terms and conditions.

All counsellors at the Rotherham and Barnsley Mind counselling service work within the British Association for Counselling and Psychotherapy's (BACP) Ethical Framework for Good Practice. Copies are available on request or directly from BACP. Counsellors receive regular clinical supervision of their work.

Copies of Rotherham and Barnsley Mind's policies on confidentiality, safeguarding children and safeguarding adults are available on request.

Rotherham and Barnsley Mind will not tolerate any form of abuse, disrespect or aggravations towards our counsellors, and we reserve the right to discontinue your appointments with immediate effect if this is not respected.

If we suspect you to be under the influence of alcohol or drugs when presenting for an appointment then the appointment will not go ahead.

The service reserves the right to decline a referral or to terminate therapy if we feel it is likely to impact negatively on the wellbeing of either the client or therapist. We will always seek to discuss this with clients with the aim of identifying appropriate alternative support in these instances, on a case by case basis.

Session attendance

Counselling sessions usually take place weekly and last for 50 minutes. If you arrive late to a session, the session will still finish at the normal time or the counsellor can decide not to go ahead with it at all.

For counselling to be effective you need to make a serious commitment to attending sessions. As such, we operate the following policy with regard to missed sessions:

If you need to re-arrange your appointment this must be done with no less than 24 hours’ notice or your session will still be chargeable. If you cannot attend a session providing 24 hours’ notice is given this will not be counted towards your missed session count.
If you have two missed sessions then your therapy will be discontinued.
The service does make allowance for planned breaks in the work, as long as these are planned and agreed in advance within the previous sessions.
You will be charged your normal fee for missed sessions (except in cases of genuine emergency or planned breaks).

If you anticipate having trouble attending your appointments, or if your regular appointment time becomes inconvenient (due to work or childcare commitments, for example) please discuss this with us as soon as possible and we may be able to work around it or make alternative arrangements.

Assessment

You will have an assessment prior to your counselling appointments, which are charged at a fixed fee of £25. This will give you an opportunity to:

discuss how many appointments you require/are entitled to.
tell us any preferences you have about your counsellor.
update us on your availability for your counselling appointments.

Please note that we can only run assessments at certain times. You will be expected to attend within working hours (09.00-17.00) and should be prepared to take time off work (as a one-off) to attend if necessary.

Confidentiality

The counselling process is bound by rules of confidentiality. This means that what you say in therapy is treated as confidential to your therapist within the counselling practice. Counselling practice includes discussing clinical aspects of your work together within clinical supervision sessions and liaising with the counselling service Team Lead. All information held by the service is in accordance with the Data Protection Act 2018.

Rotherham and Barnsley Mind client privacy statement

Rotherham and Barnsley Mind is committed to protecting and respecting your privacy and keeping your data secure. By providing us with your data you are giving us consent to process your data. We will only process your personal data to provide you with the service that you have requested from us and provide anonymous feedback to our commissioners and funders.

To read our full client privacy notice please visit: https://www.rbmind.co.uk/about-us/privacy-policy/

or contact us at: 1 – 2 Highfield, Rotherham, S65 1DZ. 01709 919929

Please indicate that you accept the terms and conditions of the counselling service by clicking below.

If you do not agree then unfortunately we will not be able to accept your referral.

Single Checkbox Field *

I accept the above terms and conditions

Custom Captcha *

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Child Referral Form - Step 1 of 4

Young Person Referral Form

Please note this form is for Young People under the age of 18 years.

First Name of Young Person *

Last Name of Young Person *

Gender (Identifies as) *

Date of Birth *

Contact phone number *

Email

Address

Post Code

Please provide us with your GP details

Surgery

Telephone

Current School / College / Other Attending *

Please provide us with details of the person making the referral

First Name *

Last Name *

Contact phone number *

Email Referral

Please check if you give us permission to: *

Leave messages on your home phone
Leave messages on your mobile phone
Text you on your mobile phone
Send you a message by email

Address

Post Code

Is the young person aware of this referral? *

Yes
No

Would you require a ground floor room for your appointments? (For example, due to physical disability).

Yes
No

Do you have any communication or accessibility needs which would affect your ability to access counselling?

Yes
No

If 'yes', please give brief details.

Please give a brief outline for your reason for referral *

Ethnicity

Do you consider yourself to have a disability?

Have you been diagnosed with an Autistic Spectrum Condition (ASC)?

Is the young person on the SEN register? *

Yes
No

Is the young person receiving support from any of the following services?

Child & Adolescent Mental Health (CAMHS)
Educational Psychology Services (EPS)
Early Help
0 - 19 Service
Police
Social Care
Youth Offending Team
Other

What is this Other service?

Where did you hear about Rotherham & Barnsley Mind? *

Terms and conditions

Counselling is a deliberately undertaken activity and relationship requiring your commitment as well as that of your counsellor. As such, please read carefully the following terms and conditions which lay out what we expect from you and what you can expect from us in relation to your time in the service. By ticking the box below you agree to these terms and conditions.

All counsellors at the Rotherham and Barnsley Mind counselling service work within the British Association for Counselling and Psychotherapy's (BACP) Ethical Framework for Good Practice. Copies are available on request or directly from BACP. Counsellors receive regular clinical supervision of their work.

Copies of Rotherham and Barnsley Mind's policies on confidentiality, safeguarding children and safeguarding adults are available on request.

Rotherham and Barnsley Mind will not tolerate any form of abuse, disrespect or aggravations towards our counsellors, and we reserve the right to discontinue your appointments with immediate effect if this is not respected.

If we suspect you to be under the influence of alcohol or drugs when presenting for an appointment then the appointment will not go ahead.

The service reserves the right to decline a referral or to terminate therapy if we feel it is likely to impact negatively on the wellbeing of either the client or therapist. We will always seek to discuss this with clients with the aim of identifying appropriate alternative support in these instances, on a case by case basis.

Session attendance

Counselling sessions usually take place weekly and last for 50 minutes. If you arrive late to a session, the session will still finish at the normal time or the counsellor can decide not to go ahead with it at all.

For counselling to be effective you need to make a serious commitment to attending sessions. As such, we operate the following policy with regard to missed sessions:

If you need to re-arrange your appointment this must be done with no less than 24 hours’ notice or your session will still be chargeable. If you cannot attend a session providing 24 hours’ notice is given this will not be counted towards your missed session count.
If you have two missed sessions then your therapy will be discontinued.
The service does make allowance for planned breaks in the work, as long as these are planned and agreed in advance within the previous sessions.
You will be charged your normal fee for missed sessions (except in cases of genuine emergency or planned breaks).

If you anticipate having trouble attending your appointments, or if your regular appointment time becomes inconvenient (due to work or childcare commitments, for example) please discuss this with us as soon as possible and we may be able to work around it or make alternative arrangements.

Assessment

You will have an assessment prior to your counselling appointments, which are charged at a fixed fee of £25. This will give you an opportunity to:

discuss how many appointments you require/are entitled to.
tell us any preferences you have about your counsellor.
update us on your availability for your counselling appointments.

Please note that we can only run assessments at certain times. You will be expected to attend within working hours (09.00-17.00) and should be prepared to take time off work (as a one-off) to attend if necessary.

Confidentiality

The counselling process is bound by rules of confidentiality. This means that what you say in therapy is treated as confidential to your therapist within the counselling practice. Counselling practice includes discussing clinical aspects of your work together within clinical supervision sessions and liaising with the counselling service Team Lead. All information held by the service is in accordance with the Data Protection Act 2018.

Rotherham and Barnsley Mind client privacy statement

Rotherham and Barnsley Mind is committed to protecting and respecting your privacy and keeping your data secure. By providing us with your data you are giving us consent to process your data. We will only process your personal data to provide you with the service that you have requested from us and provide anonymous feedback to our commissioners and funders.

To read our full client privacy notice please visit: https://www.rbmind.co.uk/about-us/privacy-policy/

or contact us at: 1 – 2 Highfield, Rotherham, S65 1DZ. 01709 919929

Please indicate that you accept the terms and conditions of the counselling service by clicking below.

If you do not agree then unfortunately we will not be able to accept your referral.

Single Checkbox Field *