Private Individual Referral - The Talking Rooms - Counselling & Psychotherapy in Glasgow

1About You

2Contacts

3Referral

4State of Wellbeing

5Sessions

6Referrer

7Submit

Referral Type*

Please fill in all fields with the referred's details - you will have an opportunity to fill in your details before submitting.

Name*

First Last

Phone*

Email*

How Do You Identify?*

Date of Brith*

DD slash MM slash YYYY

Address*

Street Address Address Line 2 City Post Code

Your GP

GP Name or Name of Surgery*

Surgery Address

Street Address Address Line 2 City Post Code

Your Emergency Contact

Emergency Contact Name*

First Last

Emergency Contact Phone*

Your Relationship to the Emergency Contact*

What is the Reason for Your Referral?*

Do you have a medical or mental health diagnosis that you are aware of?*

Do you consider yourself to be at risk of harm to self or to others at this time?*

Are you currently considering suicide?*

Have you made a plan to end your life?*

For urgent mental health support please contact your local GP or NHS 24 on 111.

Or contact one of the following crisis services:

Samaritans: 116 123
Breathing Space: 0800 83 85 87
Scottish Women's Aid: 0800 027 1234
Rape Crisis: 08088 01 03 02

Are you considering or engaging in self harm?*

Are you currently receiving treatment or support from another service?*

Are there any barriers that would stop you from accessing weekly treatment?*

Are you currently attending work?*

What would be your session preference?*

Online

Face to Face – Glasgow (Morris Park J1 M74)

Face to Face – East Kilbride (EK Business Centre)

Select all options that may be suitable.

When would be a good time for your sessions?*

Monday Morning

Tuesday Morning

Thursday Morning

Wednesday Morning

Friday Morning

Monday Afternoon

Tuesday Afternoon

Wednesday Afternoon

Thursday Afternoon

Friday Afternoon

Monday Evening

Tuesday Evening

Wednesday Evening

Thursday Evening

Friday Evening

Select as many as you wish

What is your relationship to the referred?*

Referrer Name*

First Last

Consent of the Referred*

I confirm that I have the consent of the referred to submit a referral on their behalf

Is there anything you would like to add?

Personal Data Consent*

I confirm that I have read and understood how the personal data submitted in this form is handled and retained The Talking Rooms' Privacy Policy .

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Comments

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