Renewal Therapy Service - Referral Form

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Please fill out this form as honestly and fully as you can. All personal data is stored securely and your confidentiality and privacy is our priority.

Please note, we are not an emergency service and only view referral forms in office hours. If you are at immediate risk of harm or you are experiencing suicidal thoughts, please call 999 now.

Name *

Date of Birth *

YYYY

Address *

Telephone *

Email Address *

Name of GP *

Address of GP *

GP Telephone Number *

What is the best way to contact you? *

Phone

Post

If phone is your preferred method, can we leave a message if we don't get through?

Yes

Clear selection

What is the reason for seeking help? (This is so we can connect you to the right person) *

Tick all that apply

Low mood or anxiety

Spiritual issue

Relationship issues

Identity issue

Other:

Required

How long has this been going on? *

In the last month

6 - 12 months

Less than 5 years

Longer

How is your day to day function affected? *

I am not functioning at all

I am having some problems

I am functioning as well as ever

Have you any history of risks, including suicide, self-harm, substance misuse etc? *

Are you currently experiencing any suicidal thoughts, self harm or substance misuse issues? *

What previous help have you received? *

None

Counselling or psychotherapy

Psychiatrist or inpatient

Required

Is anyone helping you at the moment? *

Yes

Maybe

If yes / maybe, please give details

How did you hear about us? *

Submit

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