Referral - EACH Counselling and Support

EACH Counselling and Support – Referral Form

Complete the routing questions first. The form will show only the sections relevant to your referral.

Routing

These answers determine which form sections you need to complete

Answer all five questions below. The form will automatically show the correct sections based on your answers.

Borough *

Please select a borough.

Age Group *

Please select an age group.

Primary Reason *

Please select a primary reason.

Gender *

Please select a gender.

Are you a self-referral or a professional referral? *

Please select a referral type.

Referral Details

Professional referral information

Name of Referrer & Organisation *

This field is required.

Contact Details of Referrer *

This field is required.

Telephone of Referrer *

This field is required.

Email of Referrer *

This field is required.

Is the client aware of this referral? *

This field is required.

Do you have the client's consent to refer? *

This field is required.

Client Details MANDATORY

Required for all referrals

First Name *

This field is required.

Surname *

This field is required.

Date of Birth *

This field is required.

Postcode *

This field is required.

Address *

This field is required.

Telephone *

This field is required.

Mobile

Is it safe to leave a message?

Gender *

This field is required.

Ethnicity *

This field is required.

Nationality

Religion *

This field is required.

Disability / Special Needs

First Language / Language Preferred *

This field is required.

Interpreter Needed

Dependent Children *

This field is required.

Emergency Contact

Emergency Contact Name *

This field is required.

Relationship *

This field is required.

Number *

This field is required.

Address *

This field is required.

GP Details

Registered with GP? *

This field is required.

GP Name & Practice *

This field is required.

GP Address *

This field is required.

GP Tel *

This field is required.

DV Form – Ascent / DVAftercare

Domestic Abuse referral – Female only

Is the client under 18? *

This field is required.

Is your gender different to the gender assigned at birth?

Sexual Orientation

Relationship Status

Preferred contact method *

This field is required.

Are there safety concerns about how you are contacted? *

This field is required.

Where does the client currently live? *

This field is required.

Do you consider your current accommodation safe? *

This field is required.

Who was the abuse from? *

This field is required.

Current status between client and this person *

This field is required.

Does the client have children or is currently pregnant? *

This field is required.

Are other services involved around children?

Nature of Concern *

Current or past domestic violence or abuse Trauma Mental Health Issues Homelessness / Housing Issues Offending History Self-harm and/or Suicide Attempt Past problematic substance use Currently using drugs or alcohol

Level of need *

This field is required.

Substance use or mental health need?

Medical history and current medication

Other agencies / professionals involved

Any other important information

Reason for Referral *

This field is required.

Young Person Form (11–17 yrs)

Brent borough only – Under 18

Age *

This field is required.

Has the young person agreed to this referral? *

This field is required.

Can the client be contacted at home? *

This field is required.

Are parents / carers aware of starting support? *

This field is required.

Background history / substances the young person is using *

This field is required.

Are Social Services involved? *

This field is required.

Involved in gang related activity? *

This field is required.

Involved in selling drugs? *

This field is required.

Working with YOT Team? *

This field is required.

Needs an interpreter? *

This field is required.

Has learning difficulties? *

This field is required.

Presents with risks (self-harm / sexual abuse / parental substance misuse)? *

This field is required.

Locations in borough that present a risk? *

This field is required.

Details of any Yes answers above

Housing Form

Harrow borough only – Male and Female

Urgent Referral? *

This field is required.

Reasons for Priority

Mental Health Issues Physical Health Issues Pregnancy (Due Date) Dual Diagnosis Substance Misuse Risk of Homelessness Carer Dependent Children

No Fixed Abode?

OK to contact at this address?

Main Reason for Referral

Tenancy Support Debt / Financial Problems Offending Alcohol / Drug Misuse Family / Carer of someone with substance misuse

Home visit required?

Outreach visit required?

Two workers required?

Type of Housing *

This field is required.

Recourse to Public Funds

Other Agencies Involvement

Full details of housing-related issues *

This field is required.

Peer Support Form – Star Centre

Hounslow borough only – Female only

Does the applicant have a personal budget?

Does the applicant have a CPA?

Has the applicant used the Resource Service previously?

Reason for Referral

Social Inclusion Volunteering Better manage mental health Better manage physical health Other

Primary reasons for the referral – applicant's wishes & aspirations *

This field is required.

Physical Health – issues impacting engagement

Mental Health – diagnosis, impact on daily life *

This field is required.

Medication – issues impacting use of service

Risks

Triggers

Successful Responses

Daily Living Skills

Substance Misuse / Addiction including alcohol

Other relevant information (cultural / religious needs)

Where did you hear about Star Centre?

Professionals currently working with applicant *

This field is required.

Mental Health Form – Tamil / Mosaic

Mental Health (Hillingdon, Female) / Refugee & Asylum (Hounslow & Hillingdon, Male & Female)

MH Diagnosis / Disability / Additional Needs *

This field is required.

Languages Spoken *

This field is required.

Residence Status *

This field is required.

Nature of Concern *

Mental Health (anxiety, depression, paranoia) PTSD Domestic Violence Alcohol Misuse Substance Misuse Other (please specify)

Medical history and current medication

Other agencies / professionals involved

Reason for Referral – brief points on client needs *

This field is required.

Substance Misuse Form – Jasmine

Ealing borough only – Female only

Is the client 18+? *

This field is required.

Borough of residence *

This field is required.

Nature of Concern

Medical history and current medication

Other agencies / professionals involved

Reason for Referral *

This field is required.

General Enquiry

No matching service – your enquiry will be recorded

Based on your selections, there is no specific service available for your combination of borough and reason. Please complete this short enquiry form and a member of the team will be in touch.

Age *

This field is required.

Gender *

This field is required.

Borough *

This field is required.

Categories of Issues *

Domestic Abuse Mental Health Housing Substance Misuse Peer Support Refugee / Asylum Young People Other

General Notes – brief description of presenting problem *

This field is required.

✅

Referral Submitted Successfully

Thank you. Your referral has been received by EACH Counselling and Support.
A member of the team will be in touch shortly.