Referral Form - Tanya's Hope & Heal Therapy
Thank you for taking the time to complete this referral form. Please answer as best you can to see whether we can arrange an initial consultation.  By completing this form, you consent to this data being collected and stored. Your data will be kept confidential except in the rare case of disclosure of involvement in terrorism, money laundering, or threat to life (information will not be shared without your knowledge). This data will be deleted if we do not proceed with working together.
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Email address
Title
Full name *
Sex *
Date of birth *
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First line of address *
Town/City *
County *
Postcode *
Best contact tel / mobile number *
Emergency contact name and number
GP surgery name  *
GP address and contact number / email  (I will not contact without consent) *
Do you have a mental health diagnosis? If yes, please specify
Do you have any other medical conditions and/or disability I should be aware of?
Are you currently taking medication? If yes, please specify.
Have you ever attempted suicide and/or experience suicidal thoughts?
If you have attempted suicide, when?
What is your current level of suicide risk? *
Have you had any previous experience of counselling / psychotherapy? If yes, when and for what reason?
What has led you to seek therapy now? *
Expectations/goals for therapy?
What is your availability to meet? *
Therapy setting *
If you prefer in person, are there any accessibility / mobility requirements I should be aware of?
Session fees - sliding scale (based on gross household income) to promote accessibility of the service. Please select the relevant amount. *
How did you hear about Tanya's Hope & Heal Therapy?
Any other information you think is relevant for me to know before we begin working together?
Any questions?
I confirm that the information I have provided here is accurate and complete. *
Client signature *
Parent/guardian signature (if under 18 years)
Today's date
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