Referral Creation Wizard

Complete the following referral form to submit a request for service to New Life Counselling .

Client

Personal Information

Enter the client's forename.
Enter the client's surname.
Enter a contact number for the user.
Enter the client's email address.

 

Please enter the client's date of birth (format: dd/MM/yyyy)
If client is younger than 16, please complete a guardian.
Please select the clients gender.

Address Information

Enter a street and house number.
Optionally enter a town.
Optionally enter a county.
Optionally enter a country.
Enter a postcode area and code.

Preferences

Are ground floor facilities required
If they are, please provide some detail regarding this.

Special Requirements

Please select any special requirements you might need (Select all applicable)

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Please select a project.
Please select a service.

Please select a referral source from the list below.

Enter the current school being attended.

Issues

Please give brief details about the situation for which counselling is being requested (including any medical / family history).
Please select a how did you hear about us option.
Please tick if you have used this service before.
If you have used the service before, please give us some details on this.

My Issues *

Select one or more of the issues you are experiencing.

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GP and Referrer

General Practitioner Details

Please select your GP from the list below.

If your general practitioner doesn't exist in the list above tick this checkbox and complete the new GP form.

Referrer Details

Please select your referrer from the list below.

If your referrer doesn't exist in the list above tick this checkbox and complete the new referrer form.

Family Members

Family Member Information

Tick if this family member may attend appointments.
Enter family members forename.
Enter family members surname.
Enter family members date of birth.
Select the family members relationship.
Select the family members gender.
Enter family members contact number.

Address Information

Tick if you would like to copy the address from the primary client.
Enter a street and house number.
Optionally enter a town.
Optionally enter a county.
Optionally enter a country.
Enter a postcode area and code.
  • No family members added.

Consents

How we use client information

We may use client information to carry out our obligations arising from any contracts entered into by the client and us. We promise to keep your details safe and secure. We will not share your information with third parties for marketing purposes. We may contact you to let you know about other services, events or for evaluation purposes.

The circumstances when details can be shared include:

  • When a counsellor has good grounds for believing that a person may cause serious harm to themselves or others.
  • When we are instructed by a court to disclose information.
  • When a person discloses criminal activity, or knowledge of criminal activity, this includes statutory obligations.
  • When it is necessary to uphold child protection laws.

Your responsibility

We would ask that you keep us informed (by email, telephone, or in writing) of any changes in your personal data so that we may have our records up to date at all times. If you wish to withdraw your consent please contact us (by email, telephone, or in writing). You have the ‘right to be forgotten’, which means you can request the deletion or removal of personal data where there is no compelling reason for its continued processing.


Access permission

I consent that you can share details with my GP and other 3ʳᵈ parties who are involved in the contract entered into by you and us

Communication Permission

I consent that I'd like to hear from you via email

I consent that I'd like to receive SMS texts from you

I consent that I'd like to receive letters from you

I consent that I'd like to receive phone calls from you

By removing a Tick above we will not contact you via this method.