CCTS Counselling Referral Form

Thanks for approaching CCTS for help....

This is a confidential and encrypted form and will be used by our initial assessment and consultation team to provide you with the best support we can.

Some questions are included to enable us to monitor the diversity of people requesting counselling and to identify areas for improvement. Thanks for your help with this.

The form should take around 15 to 20 minutes to complete. Once submitted, we will aim to respond to your request within 5 working days.

Your full name:

Home address:

Phone Number (mobile or landline)

Email address

Emergency Contact Name and number

We will only use this in an emergency

What is your date of birth?

How would you describe your gender? This information is to help us allocate a counsellor to you.

Male

(including transgender men)

Female

(including transgender women)

Prefer to self describe

(e.g. non-binary, gender-fluid...)

Prefer not to say

As you selected 'Other...' please describe...

What is your primary language?

What is your current occupation?

What are your living arrangements? Please tick all that apply

With partner

With parents/carer

Live alone

Shared accommodation

Temporary accommodation

With children under 5

With children over 5

With a full time carer

Do you have any brothers or sisters?

Yes

Child Name

Age

Are they receiving professional support?

Yes

Please provide details of the service, lead professional and contact details

Do you have any children?

Yes

Child Name

Age

Are they receiving professional support?

Yes

Please provide details of the service, lead professional and contact details

Do you have another child?

Yes

Child Name

Age

Are they receiving professional support?

Yes

Please provide details of the service, lead professional and contact details

Do you have another child?

Yes

Child Name

Age

Are they receiving professional support?

Yes

Please provide details of the service, lead professional and contact details

Do you have another child?

Yes

Child Name

Age

Are they receiving professional support?

Yes

Please provide details of the service, lead professional and contact details

Do you have another child?

Yes

Child Name

Age

Are they receiving professional support?

Yes

Please provide details of the service, lead professional and contact details

When was the last time you met with your GP (in person or online/phone)

Please provide GP practice details

(e.g. your doctors name, the address of the surgery)

Are you taking any medication, and if so, please specify:

Do you have any medical conditions?

Yes

Please let us know of any additional needs that we need to be aware of

(e.g. physical or visual impairment, diagnosis etc)

Is there any known family history of psychiatric or mental health problems?

Yes

How would you describe your childhood?

Have you ever been admitted to hospital for your psychological health?

Yes

Please tell us when this was and the reason(s) why.

Do you drink alcohol?

Yes

How frequently and how many units on average?

Have you ever used non-prescribed drugs?

Yes

What have you used and when?

Do you have any plans at the moment to harm yourself or others?

Yes

I would prefer to discuss at my initial consultation

Do you, or have you, ever self-harmed or considered it?

Yes

I would prefer to discuss at my initial consultation

Have you ever had suicidal thoughts or attempted suicide?

Yes

I would prefer to discuss at my initial consultation

Are you in danger of being harmed by someone else?

Yes

I would prefer to discuss at my initial consultation

Do you feel safe at home?

Yes

I would prefer to discuss at my initial consultation

Have there been any significant events in your life that have impacted you?

Yes

I would prefer to discuss at my initial consultation

Please provide some more information about the event(s)

Have you had therapy or counselling before?

Yes

When was it and who was the therapist?

What was the reason and how many sessions did you have?

What areas of your life are currently being affected? (e.g. work, relationships, social life, personal wellbeing, self confidence etc)

Who do you have for support in your life? (e.g.friends, family, colleagues etc)

What would you like to achieve from therapy?

Which type(s) of therapy would you like or be interested in? Tick all that apply

Online

Zoom or WhatsApp for example

Face to Face

In a counselling room (in Southampton)

Walk & Talk

In a public space (within the Hampshire area)

Telephone

Mobile or landline

Over a secure and encrytped service

If you attend a church or faith community within Hampshire or the surrounding area, please let us know which one. This is to ensure confidentiality and to help us to allocate a counsellor to you.

Please let us know how you heard about the service...

Word of mouth Picked up or given a flyer Social Media post Website or Search Engine (e.g. Google) Other

Please tell us where you picked up a flyer from...

Please tell us which social media platform you found us on...

e.g. Facebook, IG, Twitter, Linkedin etc..

As you selected 'Other', please let us know how you heard about us...

Thanks for taking the time to complete this form - please submit it using the button below and we will get in touch with you.

Your information will be encrypted.

CCTS Counselling Referral Form

Central Counselling & Training Service