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Counselling Referral

First name

Last name

Email

Phone

Best means of contact?

Ethnicity? (please select 1 option)

British

Irish

Gypsy or Irish Traveller

Any other white background

White and Black Caribbean

White and Black African

White and Asian

Any other mixed

Indian

Pakistani

Bangladeshi

Chinese

Any other Asian background

Caribbean

African

Any other Black background

Arab

Any other

Not stated

Birthday

Gender identified as?

Who recommended First Stop to you? - person/organisation (If Applicable)

Refferal Type

Upload File

Upload supported file (Max 15MB)

website risk assessment outside agency.docx

Street Address

Street Address Line 2

City

County

Postal code

GP Surgery

Any special needs first Stop needs to be aware of?

Medical conditions and medications being taken?

Please state the special needs?

Brief description of issues you would like to explore within counselling?

What support networks do you have?

Please tick if you identify with any of the following:(failure to provide correct details may result in termination of services)

Safeguarding

Violence & Aggression

Learning Disabilities

Mental Health

Substance Misuse

Weapons

Physical Health

Sex Offender

None of the above

Please give as much up to date information as possible?

By signing and submitting this form; I declare the information given to be up to date and correct at the time of completion.

Your Signature

I accept terms & conditions

Thanks for completing the form; A counseling co-ordinatior will be in touch during working hours.

Professional Referral document (Not for Self Referral)

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29 Bocking End, Braintree, CM7 9AE

Tel: 01376 346535

Email - contact@firststopcentre.onmicrosoft.com

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