New College Lanarkshire Referral - The Talking Rooms - Counselling & Psychotherapy in Glasgow

1About You

2Contacts

3College

4Referral

5State of Wellbeing

6Sessions

7Referrer

8Submit

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*

GP 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*

Student ID*

Which campus are you attending?*

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?*

When would be a good time for your online 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

How did you hear about us?*

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 .

Disclosure*

I agree to the disclosure policy.

Please be advised that your work will be confidential with The Talking Rooms, however, the New College Lanarkshire student support team, will be aware that you are being supported by a counsellor from The Talking Rooms and will receive a copy of this referral. They may also be in touch to offer additional support to you.

If at any time during your work with The Talking Rooms, there is a disclosure that relates to risk to your life or others or The Talking Rooms are concerned for your general safety or that of another, confidentiality will be broken and the safeguarding concern shared with the safeguarding team at New College Lanarkshire who may then make direct contact with you or your GP.

By submitting this referral you agree to this process being in place.

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.