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

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*

Phone*

Email*

How Do You Identify?*

Date of Brith*

Address*

Street Address Address Line 2 City Post Code

GP Name*

GP Address*

Street Address Address Line 2 City Post Code

Emergency Contact Name*

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:

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 is your relationship to the referred?*

Referrer Name*

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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