Create Referral

Fill in the form below and click on the Create Form button at the bottom of the screen.

This will create a Referral Form that you can email to us and also keep a copy for your own records.

Click the "help buttons" in each section if you want further guidance on completing the form.

Personal Details Section

Personal Details Section

In this section of the form, enter the details of the person being referred.

If you hover your mouse over each box a note explaining what to put in will appear.

Please fill in as many details as you can - and note that some boxed are mandatory. If you miss out one of these boxes it will be highlighted when you submit the form

This section of the form MUST be completed for all referrals.

Title:
Enter the title of the person being referred: Miss, Mrs, Mr etc.
Forename:
Enter the first of the person being referred.
You must enter something in this box.
Surname:
Enter the surname of the person being referred.
You must complete this box.
Occupation:
Enter the job or occupation of the person being referred.
Date of birth:
Enter the date of birth of the person being referred - in the format dd/mm/yyyy.
You must complete this box.
Phone:
Enter a contact telephone number for the person being referred.
Age:
Enter the age of the person being referred.
You must complete this box.
Address:
Enter the 1st line of the address for the person being referred.
You must complete this box.
Disabilities:
Enter a note of any disabilities that the person being referred has.
Enter the 2nd line of the address for the person being referred.
Religion:
Enter the religion of the person being referred, if any.
Enter the 3nd line of the address for the person being referred.
Ethnicity:
Enter the ethnicity of the person being referred.
Town:
Enter the town name of address for the person being referred.
You must complete this box.
Sexuality
(optional):
Enter the sexuality of the person being referred.
This information is optional.
Postcode:
Enter the postcode for the person being referred.
You must complete this box.
Email Address:
Enter an email address for the person being referred.
If you do not have an email address, enter NO EMAIL.
Date of Referral:
Enter the date that you are completing the referral - in the format dd/mm/yyyy.
You must complete this box.
Is this a self-
referral?
Are you completing this referral for for yourself?
If so check this box and skip the 'Referring Agent' section - and go straight to the 'Client Needs' section.
If so, please check this box and ignore the next section

Referring Agent Section

Referring Agent Section

If you are completing this referral form as agency you MUST full complete this section.

If you are an individual completing this form on your own behalf, you do not need to complete this section.

Referring Agent Details:

AGENCIES: THIS PART MUST BE FILLED IN FOR US TO ACCEPT YOUR REFERRAL
SELF REFERRAL: THIS PART DOES NOT NEED TO BE COMPLETED
Name:
Enter the name of the person at the agency completing the referral.
For agency referrals you must complete this box.
Agency:
Enter the name of the agency completing the referral.
For agency referrals you must complete this box.
Address:
Enter the 1st line of the address for the agency.
For agency referrals you must complete this box.
Enter the 2nd line of the address for the agency.
Enter the 3rd line of the address for the agency.
Town:
Enter the town of the address for the agency.
For agency referrals you must complete this box.
Postcode:
Enter the postcode of the address for the agency.
For agency referrals you must complete this box.
Phone:
Enter the contact phone number for the person at the agency making the referral.
For agency referrals you must complete this box.

Client Needs Section

Client Needs Section

On the left-hand-side of the section tick the appropriate boxes to tell us the areas you need support in - tick all of the boxes that apply.

Also tick the boxes to tell us about how to contact you and whether you are comfortable with seeing a male counsellor. Again, tick all of the boxes which apply.

In the large box on the right-hand-side of the section enter as much information as you can to give more information about the support you need. You can include around 450 words in this box so please make use of this and provide as much information as you can.

This section of the form MUST be completed for all referrals.

Please tell us if you are affected by or require any
support with any of the following by ticking
the appropriate tick a box(es) below:
Then please also provide further details in the large box below:
Child protection
Select this checkbox if the referral relates to a child protection issue.
Make sure that you include an explanation of this in the large box to the right.
Drug & Alcohol misuse
Select this checkbox if the referral relates to a drug or alcohol misuse issue.
Make sure that you include an explanation of this in the large box to the right.
Mental health issues
Select this checkbox if the referral relates to a mental health issue.
Make sure that you include an explanation of this in the large box to the right.
Domestic abuse  
     Was it in the past?
Select this checkbox if the referral relates to a domestic abuse issue and it happened in the past.
Make sure that you include an explanation of this in the large box to the right.
     Is it happening now?
Select this checkbox if the referral relates to a domestic abuse issue and it is happening now.
Make sure that you include an explanation of this in the large box to the right.
Is there anyone who you do not want
to know about this referral?
Select this checkbox if there is anyone who you do not want to know about this referral.
Make sure that you include an explanation of this and tell us who you do not want to know in the large box to the right.
Is is safe for us to call on the number
given above?
Select this checkbox if it is safe to call you on the telephone number you have provided.
Is is safe for us to leave a voicemail?
Select this checkbox if it is safe for us to leave a voicemail message on the telephone number you have provided.
Are you comfortable with seeing
a male counsellor?
Select this checkbox if you comfortable with seeing a male counsellor.
 

Form Creation

Form Creation and Next Steps

Having completed all of the boxes that you need to above, you are ready to create the referral form by clicking the button down to the left.

When you do this the information you have entered will be collected together and the printable referral form will be displayed.

As well as being able to print it, you can save this form as a "pdf document" which you can email to us at info@reachoutcounselling.co.uk.
Use the "save page" function of your browser to save this "pdf document".

Note that you cannot edit the printable referral form. Please check the information included on the form and if you want to change anything, use your browser's "back" button and you will be returned to this page.

 

To contact Reach Out Counselling:

info@reachoutcounselling.co.uk
Tel: 07790 772942