Support Referral Form | Survivors In Transition

Client Details

Full Name*

Date Of Birth*

Gender

Ethnicity

Landline

Mobile

Email*

House Number

Postcode*

Preferred method of contact

Text
Email
Phone

Can we leave a message?

Yes
No

Name of GP*

Phone number

Referral Details

Referred by*

Organisation
Self

If Self referral, how did you hear about SiT?*

If referred or signposted by an organisation, referrer please supply the following details:

Organisation Name*

Name of referrer*

Role*

Referrer Phone No.*

Email*

We will contact the referrer in the event we cannot make contact with the client

Confidential Information

Are you currently taking any medication

Yes
No

If yes, please list*

Do you have a mental health diagnosis (eg Personality disorder, schizophrenia etc)*

Yes
No

If yes, please provide details*

Do you consider yourself to have a disability?*

Yes
No

If yes, please provide details*

Are there any risks we should be aware of (to self or others) ?*

Yes
No

If yes, please provide details*

Is client working with any other organisations / agencies?*

Yes
No

If yes, please provide details*

Is client currently receiving counselling / therapy?*

Yes
No

If yes, please list*

Do you prefer to have an assessment in Ipswich or Bury St Edmunds?*

Ipswich
Bury St Edmunds
No preference

During busy periods at SiT when we anticipate a waiting time we are able to offer affordable, paid counselling with one of our qualified therapists. Would this be something you would be interested in?*

Yes
No

Brief reason for referral (what you feel you need help with)

Confidentiality, Information Sharing & Safeguarding Statement – To be agreed by client

I agree to this information being shared with and between agencies I am currently involved with, including my GP. I understand that this information is being shared with a view to ensuring and assisting the continuity of my care. I am aware that I can withdraw my consent to this information being shared with any or all of these agencies at any time.

As per our safeguarding and confidentiality policies the information you provide is confidential and will not be disclosed to another party unless you disclose information that implies you, another person or a child is at risk, in which case this will be passed to our Safeguarding Lead to decide what action to take– we will endeavour to inform you before any action is taken

Client Name

Please tick box*

I agree to the Confidentiality, Information Sharing & Safeguarding Statement detailed above