REFERRAL FORM FOR ADULTS (18+) 2021 Working Agreement and Referral Form for Remote (Online and Telephone) Counselling
Please take some time to read this contract carefully.

If there is anything that you are not sure about please email our admin team at onlinetherapy@counsellingdoncaster.com, or phone us on 07765224564.

Due to the COVID-19 (Coronavirus) pandemic Open Minds currently offer 10 sessions of online and telephone counselling. We have limited in person face to face counselling which is being prioritised to children and young people.

This form will serve as an explanation of how this approach works. This is also a contract that you agree to if you choose to press submit at the end of the form.

Please note that your counsellor cannot refer you directly for support with financial, food or medical issues during lockdown (we can signpost you to support) so if this is the main reason for your referral here we recommend you contact the community hub for support directly:
https://www.doncaster.gov.uk/services/health-wellbeing/community-hub-for-coronavirus-support

You can also find other sources of support on our lockdown website: www.openmindslibrary.com which is constantly being updated.
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Email *
About your counsellor
Your counsellor will use a person-centred approach and will not give you advice or tell you what to do about decisions in your life. The counsellor will help you explore the areas in your life which you choose to discuss. They will help you gain a better understanding of your experiences, relationships and what you can change. The counsellor provides a non-judgemental hour in which you can explore the issues which matter to you, at your own pace. *
Yes
I confirm that I have read and understood this section
What remote counselling means:
FOR Adults Open Minds offers Online Counselling during the pandemic where face to face online counselling is not possible. This includes: • Webcam sessions on Zoom/Doxy/other platform • Telephone counselling *
Yes
I confirm that I have read and understood this section
The counsellor will be alone in a separate room in their home or at Open Minds when they contact you and will ensure that no other members of their household have access to them during the session. *
Yes
I confirm that I have read and understood this section
For online and telephone counselling we recommend that you find a private and quiet space in which to talk to your counsellor. We recognise that this is a difficult and confusing time and if this is not possible we recommend that you cancel and reschedule for another time. *
Yes
I confirm that I have read and understood this section
Open Minds’ counselling adheres to the Ethical Framework for Good Practice provided by the British Association for Counselling and Psychotherapy. *
Yes
I confirm that I have read and understood this section
Breaking confidentiality
The counsellor will only share the content of your session if they are concerned about your safety or the safety of other people.

This could be for such reasons as:
1. If you are at serious risk of causing harm to yourself
2. If someone else is at serious risk from your or from someone else
3. If child abuse is disclosed or a child is at risk of harm
4. If you share information about proposed act of terrorism
5. When compelled to do so by law

What breaking confidentiality might mean:

This might involve contacting social services, the police or another appropriate agency such as the NHS to request a welfare check. A welfare check is when a member of the police comes to see if you are safe and well.

The counsellor would normally tell you before taking this measure.
Please tick to indicate you have read and understood this section *
Yes
I confirm that I have read and understood this section
Making notes and record keeping
Recording: The counsellor will not electronically record your sessions. This includes transcription, video and audio recording. We ask that you also not record sessions in this manner. This is due to the risk of hacking or abuse of your data if this did occur.
Note-taking: Open Minds’ use electronic note-taking. The counsellor will make notes which are stored on Open Minds’ electronic server but accessible only by the counsellor and the Managing Director of Open Minds, or which can be shared with their supervisor if there is a concern about the counsellor’s practice or your safety. *
Yes
I confirm that I have read and understood this section
Sharing and Processing Information
Supervision: the counsellor will contact their Open Minds’ supervisor by text or phone after your session to log that it occurred. As explained above they will send electronic notes which will be stored securely. They may also discuss some of their work with you in order to improve the therapy you receive. You would be referred to only by your code during these discussions to maintain your anonymity. Your code is your first and last initial and your year of birth. *
Yes
I confirm that I have read and understood this section
ICO: Open Minds is registered with the Information Commissioners Office (ICO) as a data controller and processor and work to their standards for storing information. More information can be found at: https://ico.org.uk/ *
Yes
I confirm that I have read and understood this section
Information sharing within Open Minds. In order to support you to find the appropriate support alongside our work with you, or if you are not suitable for our service, we may discuss your needs in triage and case review meetings within our service. *
Yes
I confirm that I have read and understood this section
Information sharing with appropriate third parties. Information sharing with appropriate third parties. Open Minds will not share information without your consent, except in the event of safeguarding disclosures. Open Minds may need to talk to the professionals who refer you, or who you name in your referral, in order to obtain sufficient information to support you internally or to identify appropriate other sources of support. We would only do so with your consent. *
Yes
No
I confirm that I have read and understood this section
I consent to information sharing for the above purposes ONLY
If you have made a suicide attempt within the last 12 months you may be contacted either by Open Minds' main number or by the IMP;ACT Team who work specifically with people who have made an attempt on their lives. IMP;ACT is a subsidiary of Open Minds. *
Yes
No
I confirm that I have read and understood this section
GP's name / your registered Medical Practice *
How it works:
Counselling is a professional relationship and counsellors cannot accept friend requests on social networking sites from clients. We also ask that you do not electronically record the counselling session nor share the contents of your session on social media. *
Yes
I confirm that I have read and understood this section
Webcam sessions
You and the counsellor agree on a set day and time to meet in person, on-line or by telephone. This secure platform provides a high level of end-to-end encryption. Counselling sessions may be weekly or further apart depending on your requirements. They will last for a maximum of 60 minutes. The counsellor will log in using the account onlinetherapy@counsellingdoncaster.com or cypteam@counsellingdoncaster.com but do not have access to emails from those account and will only be available through Zoom or Doxy at the time agreed with you.
Telephone sessions
You and the counsellor agree on a set day and time for the counsellor to phone you. Their phone number will be withheld. Telephone counselling sessions may be weekly or further apart depending on your requirements. They will last for a maximum of 60 minutes.
Cancellations
We recognise that there are times when household disruption is unavoidable. Please email Open Minds’ admin team on onlinetherapy@counsellingdoncaster.com or text 07765 224564 if you are unable to attend your session.
If we do not hear from you to cancel by email, your counsellor will attempt to contact you by Zoom (https://zoom.us/download) or Doxy face to face online, or will phone you from a with-held number at the agreed session time. Open Minds reserve the right to choose an alternative application if it better suits the provision of therapy.
If you do not answer they will try again in 5 minutes, and then again 5 minutes after that. If you do not answer within 10 minutes of the agreed session time the counsellor will stop trying to contact you and will wait for you to email onlinetherapy@counsellingdoncaster.com before attempting to contact you again.
If your counsellor cannot proceed with the session due to their own illness, household disruption or problems with technology, a member of our admin team will email or text you. Counsellors do not have access to the administrative email or phone.
Please tick to indicate you have read and understood this section *
Yes
I confirm that I have read and understood this section
Payment
Open Minds recognise the difficulty of this distressing time and understand that the pandemic causes financial and emotional disruption to people’s lives. If you can make a financial contribution this would be invaluable to helping Open Minds as a Charity, both now and for the future.
Open Minds income as a charity since the pandemic began has reduced by more then 95%, and for this reason we ask for a contribution to help us keep providing our services.
We would only ask that you contribute what you can afford according to your household income.
Household MONTHLY income recommended contributions: *
To make a contribution you can send the amount of your choice online through Bank account name: Open Minds Counselling Service sort code: 20-26-55 account number: 83427757
Please make a transfer of the amount of money you have agreed to, and include your name and year of birth as reference
Please tick to indicate you have read and understood this section *
Yes
I confirm that I have read and understood this section
Further support
We recognise that it can be difficult to feel supported.

Open Minds have prepared information about sources of support still available. You can learn more at www.openmindslibrary.com

In the meantime you can:

- call the NHS on 01302566999

- call the Samaritans on 116123

You can access help for your mental health at:

- https://www.thecalmzone.net/

- https://www.nhs.uk/oneyou/every-mind-matters/
Please tick to indicate you have read and understood this section *
Yes
I confirm that I have read and understood this section
By completing the following the section you indicate you have signed and accepted this working agreement. I have read the above contract with Open Minds Counselling Services Ltd. and agree to its terms *
Yes
I have read the above contract with Open Minds Counselling Services Ltd and agree to its terms
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