Professional referral formThis form will take 5-10 minutes to complete. Your Name * First Name Last Name Job title and employer Your work phone number * (###) ### #### Your work email * Please describe the capacity in which you are working with this person * Please include what type of interventions they have already had, history of the case and any important information regarding family dynamics etc. Is your organisation funding the counselling support? * Yes No Name of the person you are referring * First Name Last Name Gender Male Female Indeterminate Pronouns She/her He/him They/their/them Their date of birth * MM DD YYYY Their address Address 1 Address 2 City State/Province Zip/Postal Code Country Main reasons you are requesting support for them * tick all that apply Low moods/depression Anxiety Relationship struggles Anger Obsessions/compulsions Self harm Addiction (drugs, alcohol, gambling) Historic trauma Victim of a crime Physical health issues impacting mental health Grief School avoidance I have issues with food I just want to talk to someone Have they seen their GP regarding their mental health? * Yes No Have they ever been referred to children's NHS mental health services (CAMHS) * Currently under the care of CAMHS or a school support alternative Yes previously but now discharged No Is their mental health affecting their education? * No Yes, they are missing some school They are missing school more often than not Their ethnicity White Mixed heritage Asian or Asian British Black or Black British Other ethnic groups Not known GP Practice * British Armed Forces * Are they or a member of their family a former or serving member of the British Armed Forces. No Serving member Veteran Family member who is serving or former member Do they have an issues with accessibility that we may need to take into account for your appointments Who should we contact to arrange an appointment Myself Someone else Thank you for taking the time to complete this referral. You or the contact will be contacted via email with information to arrange a pre-therapy appointment. Please check your junk mail for an email from admin@incharleysmemory.com. We try to respond to all referrals within 48 hours.
