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Counselling referral form

counselling referral form

Headway Surrey Counselling Service Referrals and Eligibility

Counselling Services for Acquired Brain Injury Survivors and Family/Carers

Headway Surrey is a registered independent charity (1046863) and offers short-term counselling for Acquired/Traumatic Brain Injury survivors, their carers and immediate family members within Surrey with a defined range of problems for a series of 6 sessions.  Each session is 50 minutes in length. 

We may be able to support persons from outside Surrey, however, Surrey is our number one priority   

Who can refer? 
1. Self-referral and/or family referral.  
2. Mental health services, neurological experts, GP's, or therapists and other organisations.  
3. Headway Surrey staff team. 
4. Case Managers, social workers, team leaders or rehabilitation support staff on behalf of the individual affected by brain injury 

Eligibility

This service is appropriate for: 

1. Mental health problems: For example, mild to moderate episodes of anxiety or depression, anger management, self-esteem difficulties.  
2. Unusual changes in mood or general emotional state,  
3. Problem associated with life altering circumstances, life crises, such as bereavement, illness, change in circumstances, or loss, adjustment, and acceptance issues. 
4. Problems associated with relationships (a specialist service such as RELATE may also be considered suitable in some cases). 

Payment Information

Payment 

We are a registered charity and must fundraise to provide this service. Counsellors in private practice can charge up to £90 per individual session, and it is important that you are aware of this, so that you gain maximum benefit from our service.

  • We need you to donate £25 per session towards each session, in advance.
  • Preferably before starting you will pay for all 6 sessions in advance.  If this is a problem, then you can pay weekly before each session, but this costs us more in administration time, so we prefer not to.
  • As this is a donation of £150 towards the counselling, you may wish to gift aid this, you just need to make us aware.
  • In some circumstances, we will allow an extra 2 sessions, after the 6th session.  These will require a donation of the same rate of £25 per session in advance of each session.
  • The donation can be via cash, cheque, BACS or our website. Your counsellor will instruct the Headway Surrey Finance Team to contact you and arrange the donation (and gift aid if applicable).Additional donations are always invited and welcomed from counselling clients at any time.  Details of how to do this will be located on your Feedback Questionnaire sent out at the end of the sessions and on our donate page. /donate
Data Protection and Information Sharing

We adhere to strict data protection and confidentiality protocols.  In conversation with you, if you have been referred to this service by an agency, with your permission, we will keep that agency, or other relevant organisations, informed as to the continuing appropriateness of our counselling service for you.  

When you have completed your course of counselling with us, with your permission, again, we will contact the agency that referred you to provide a summary of your progress.  This summery will be written with or in coordination with you and will only be disclosed to those who you give permission too.  

This summary can/will include:  

  • How many sessions you attended? 
  • What was beneficial and themes of what was discussed (if appropriate) 
  • Any strategies or outcomes that the counselling client finds beneficial  
  • Any memory aids used or suggested (if appropriate)  
  • Whether an onward referral or signposting is needed.  

If a counsellor has any concerns that you are: 

  • at risk of harming yourself 
  • at risk of harming another person
  • at risk of being harmed by another person 

Headway Surrey will make a referral to relevant agencies (if appropriate, including where a client has been referred by an agency, informing that agency of the counsellor’s concerns). However, we will always inform you of this disclosure first and what / who will be told of the concerns. This will form part of your contract in your initial session with your counsellor.   

Headway Surrey is obliged to report any concerns it may have about the safety of a child or vulnerable adult to the appropriate agency. This will be discussed with you should this be appropriate step or outcome of a session content.  

We strive to maintain a safe and high-quality Counselling Service and therefore have to follow the procedures describe above. 

If you are unable to complete this form, please contact a member of our team who can assist you:

Email: referral@headwaysurrey.org
Phone: 01483 454433

Name
16/07/1971
Address
Preferred forms of contact
Will you need a reminder of your session the day before?
Is this a shared email address?
Is the person seeking counselling
How would you prefer your sessions to be delivered?

Further information

We collect the following information about our clients for monitoring purposes only. You are not obliged to complete any parts of this section.

Lead client support/next of kin details

Name of Support Person or Next of Kin
example: 16/07/1971
Address
Do we have permission from the person seeking counselling to contact or make arrangements via the lead support person?

GP details (required)

As good practice we will notify your GP of our work with you and send a letter of engagement to be placed on your medical file.
GP name
GP surgery address

Data Protection Statement and Sharing Agreement - Service Users

Personal information which you provide to Headway Surrey will be processed in accordance with the General Data Protection Regulation (GDPR) 2018 and the Data Protection Bill 2018 and will be used for the following purposes: to enable Headway Surrey to create an electronic and paper record of your needs and to ebale the support you need to be arranged to enable Headway Surrey to keep you informed of our services, news and events to enable Headway Surrey to compile statistics for reporting purposes. The information you provide to us will be stored and processed securely as paper records, electronic records and/or on our database system (CRM). all records and data will be held locally or on UK/EU data centres. A full copy of our Data Policy is available on request.
I agree to my data being stored in this way
Data may be shared with organisations that we have a formal relationship with trhough a contract or data sharing agreement if you give permission for this to happen. Data may also be shared with other people and organisations involved in your treatment or care or who can help provide the support you need. I agree to my information being shared with, as appropriate, my GP, other medical or health care professionals involved in your treatment and care, relevant Social Care Teams, relevant housing associations and local authority housing services, Citizens Advice, DWP, organisations involved in your care (for example, providing support to you at home or in the community), NHS Mental Health Services, organisations involved in your transport to and from our services, organisations appointed to manage your Personal Budget/Direct Payments, Solicitors and Case Management Companies acting for you, family members and carers acting on your behalf.

Consent

I confirm I have read and understood the information provided within this referral form regarding eligibility for the service, data protection and information sharing.
Full name
TYPE YOUR NAME IN CAPITALS
Upon receipt of this application form, if you meet the Counselling Services eligibility criteria, you will be offered an initial assessment appointment, dependent on which you may be offered 5 more sessions for a total of 6 sessions. Throughout your block of 6 sessions, the counsellor will review your progress. In some situations, a further 2 sessions may be offered. This will be determined upon need and current waiting lists.