Community Counselling Referrals

Community Counselling Online Referral Form

**We are unable to accept new referrals for Brief Counselling due to excess demand in Ryedale and lack of funding in Scarborough, Whitby and Filey. Please only use the form below to refer for Options or MOJ Longer Term Counselling for Victims of Sexual Violence or Domestic Abuse.**

Please complete as much of the information required as you can for your referral. We will get in touch with you as soon as possible. We are continuing to operate as a hybrid service and offer telephone, online and limited face-to-face counselling.

Date of referral*

Personal Information

Gender Client’s forename* Client’s surname*

Address

Address Line 1*

Address Line 2

Town* County* Postcode* Do not write to this address

Phone and Email

Landline

Do not leave message

Mobile

Do not leave message

Email address*

Do not send mail to this email

Date of birth

Details

Presenting issues (briefly explain the reasons for counselling)

Access Issues? Communication needs?

Any additional information in terms of risk and needs?

Referrer Details

Self-referral?

Name of person making referral (if not self referral)

Referral agency

Referrer contact details

Medical Details

Name of GP

Name of GP surgery*

NHS number (if known)

PHQ9/GAD7 scores (if known)

Captcha

Thank you, your referral form has been sent. We will reply as soon as we can.