Warwickshire Refer - Listening Ear Merseyside

Company

This field is for validation purposes and should be left unchanged.

Before we can accept a referral, you must have obtained consent to processing and sharing clients information and data.

Full details of our Data Protection Policy 'Clients information and what you/they need to know' and Privacy Notice can be viewed and downloaded at www.listening-ear.co.uk/privacy-policy.

I have obtained consent to the processing of data in relation to:

The provision of a counselling service, which may be 1:1 or group support.*

Yes

Preparation of statistics on our performance, equality and diversity for organisations who fund our charitable services. Reports do not identify individuals. They are anonymous.*

Yes

Preparation of case studies evidencing how we help people to recover for organisations who fund our charitable services. Reports do not identify individuals. They are anonymous.

Yes

Preparation of case studies to evidence how Student Counsellors help people to recover whilst on their placement with us. These are provided to the course leaders to support students to gain their qualifications. Reports do not identify individuals. They are anonymous.

Yes

I have obtained consent to information being shared in relation to:

In the event of concerns regarding risk of harm to self or others, Listening Ear is obligated to share its concerns with the most appropriate agencies which may include the GP. I therefore consent to the information provided being shared with third party agencies in the event of any such risk.*

Yes

Listening Ear may be aware of other organisations and services which may be of more/additional help to an individual. In this case, I consent to information being shared with appropriate third-party organisations for the purposes of securing such help.

Yes

The client consents to being contacted in relation to:

Activities or events which may be beneficial or of interest (e.g. Health and Wellbeing activities)

Yes

Referrer Details:

Referring Agency Name

Referrers Name

Referrers Job Title

Referring Agency address

Referrers Contact number

Referrers Email address

If you would like to be sent a copy of this form please enter your email address here

Client's details

This referral is for:*

A child or young person aged 4-17 (or up to 25 with SEND)
An adult aged 18+

Title*

First name*

Surname*

Date of birth*

Address 1*

Address 2*

Address 3

Address 4

Address 5

Postcode*

Phone*

Mobile*

Email

If for any reason you need us to limit our contact, please tell us here (e.g. if you feel that by making contact we may put anyone at increased risk or if there is a safe word to use when contacting).

By providing this information you are consenting Listening Ear to contact you/the person you are referring or their parent/carer (if children's referral).

Next of Kin / Emergency Contact

Name*

Relationship*

Phone*

Email

GP Surgery

Name*

Address*

Phone*

NHS Number

Please provide the NHS number of person being referred. If this is not known please be aware that the information will be required at assessment stage in order to access our service.

For children & young people's referrals

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Is the child or young person under 17?

Yes
No

School or college (if applicable)*

Is the child or young person subject to shared parenting responsibility?

Yes
No

We recommend that the main named parent of the child authorising the referral take their own legal advice about informing or consulting the other parent.

Parent/Carer (1) Name

Parent/Carer (1) Address

Parent/Carer (1) Phone

Parent/Carer (1) Email

Parent/Carer (2) Name

Parent/Carer (2) Address

Parent/Carer (2) Phone

Parent/Carer (2) Email

Please tick if any of these apply to the child or young person:

TAF
CiN Plan
EHAT
CP Plan
DARIM
EHCP
LAC

Has an Operation Encompass call been made to the school?

Yes
No

Please give the name and telephone number of the contact for this:

Information that helps us monitor our services

Employment status

Working Full time
Working Part time
Absent from work through sickness
Retired
Unemployed and receiving benefits
Unemployed and not receiving benefits
Student/Pupil
NEET
Other

If other, please state:

Gender

Prefer to self-describe Gender (please state)

Is gender the same as that assigned at birth?

Pronouns

Prefer to self-describe Pronouns (please state)

Ethnicity

Prefer to self-describe Ethnicity (please state)

Sexual Orientation

Prefer to self-describe Sexual Orientation (please state)

Religion

Any other religion or belief (please state)

Does the client have a known disability, health condition or neurodivergent condition?

Yes
No
Prefer not to say

Does the client have a long-standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy?

Yes
No

Does the client have a mental health difficulty, such as depression, schizophrenia, or anxiety disorder?

Yes
No

Does the client have a physical disability or mobility issues?

Yes
No

Does the client have a neurodivergent condition such as autism, ADHD, dyslexia, dyspraxia, dyscalculia, or tourette's?

Yes
No

Is the client blind or have a visual impairment uncorrected by glasses?

Yes
No

is the client D/deaf or have a hearing impairment?

Yes
No

Does the client have a disability, health condition or impairment that is not listed above (specify if you wish)

Additional information that helps us to tailor our services to the client

Has the client received counselling/therapy in the past?*

Yes
No

If yes, did the client feel they benefited from this:*

Has the client accessed other Psychological services?*

Yes
No

If yes, please give details below (e.g. when, what for, how long for):*

Has the client been diagnosed with any mental health condition?*

Yes
No

If yes, please give details below*

Has the client ever received a Mental Health Assessment?*

Yes
No

If yes, please give details below*

Has the client ever had thoughts of, or have they tried to harm themselves in any way?*

Yes
No

If yes, please give details below:*

Is the client currently prescribed medication to help with psychological problems?*

Yes
No

If yes, please provide addition information (e.g. name of medication, dosage):*

Has the client had any traumatic experiences that significantly affect them now?*

Yes
No

If yes, please provide details on traumatic experiences:*

Are there any other Professionals working with them now?*

Yes
No

If yes, please give details below:*

What are the difficulties and how long have these been a problem?*

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What does the client consider to be the main difficulty?

Is the client living in "safe / relevant accommodation?"

Safe accommodation can include: • Refuge accommodation (DA support included within the accommodation) • Specialist safe accommodation (provides dedicated specialist domestic abuse support to victims of domestic abuse with protected characteristics under the Equality Act 2010 or who share a vulnerability requiring additional support) • Dispersed accommodation (self-contained accommodation with the same level of domestic abuse support as in refuge) • Second stage accommodation (with domestic abuse support for a fixed period to enable the person to move to live independently within the community) • Sanctuary scheme (enabling victims of domestic abuse to remain in their own homes through the installation of additional security to the property or the perimeter) Safe & relevant Accommodation DOES NOT INCLUDE: Bed & breakfast or temporary accommodation: • which is not separate and self-contained • where the following amenities are shared by more than one household— toilet, personal washing facilities, or cooking facilities.

Risk Assessment Information:

Date of most recent DASH / MERIT / DARIM form completed?

Most recent DASH score recorded?

Dash Score

Most recent MERIT score recorded?

Does the client have any legal or court cases pending?*

Yes
No

If yes, we will need to contact your Solicitor before progressing the referral. Please provide their full contact details:*

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Has the client ever served in the armed forces or are you a dependant on someone who has served?

No
Yes - ex-services
Yes – dependant of ex-serving member
Not stated

Does the client require an Interpreter?

No
Yes

If an Interpreter is required please specify language and dialect (if necessary)

Client Information:

Is the client registered as a carer?

Yes
No

Pregnancy/Maternity Status

None
Yes

If Yes Share details

Is the client living in safe/relevant accommodation?

Yes
No

*Supporting guidance:

Safe accommodation can include:

Refuge accommodation (DA support included within the accommodation)
Specialist safe accommodation (provides dedicated specialist domestic abuse support to
victims of domestic abuse with protected characteristics under the Equality Act 2010 or who share a vulnerability requiring additional support)
Dispersed accommodation (self-contained accommodation with the same level of domestic abuse support as refuge accommodation)
Second-stage accommodation (with domestic abuse support for a fixed period to enable the person to move to live independently within the community)
Sanctuary Scheme (enabling victims of domestic abuse to remain in their own homes through the installation of additional security measures)

Safe and relevant accommodation does not include:

Bed and breakfast or temporary accommodation which is not separate and self-contained
Accommodation where toilet, washing or cooking facilities are shared by more than one household

Warwickshire DiAmond Service Referrals

This referral page and form is solely for professionals and partners referring into the Warwickshire DiAmond service.

Referrer Details:

Client's details

Next of Kin / Emergency Contact

GP Surgery

For children & young people's referrals

Information that helps us monitor our services

Additional information that helps us to tailor our services to the client

Risk Assessment Information:

Client Information:

*Supporting guidance:

Warwickshire DiAmond Service Referrals

This referral page and form is solely for professionals and partners referring into the Warwickshire DiAmond service.

Referrer Details:

Client's details

Next of Kin / Emergency Contact

GP Surgery

For children & young people's referrals

Information that helps us monitor our services

Additional information that helps us to tailor our services to the client

Risk Assessment Information:

Client Information:

*Supporting guidance:

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