Counselling and Support - Listening Ear Merseyside

Instagram

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

You may complete this form yourself or ask someone to help you.

Before we can accept a referral, we need to obtain your consent to processing and sharing your information.

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

I 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 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

I consent to being contacted in relation to:

Activities or events which may be beneficial or of interest (e.g. Childrens Christmas Party, Memorial Service, Anniversary Cards or Health and Wellbeing activities)

Yes

Third Party Referrals

Are you making a referral on behalf of someone else?*

Yes
No

If you are making a referral on behalf of someone else, please indicate that you have gained necessary consent as above. We recommend that you share our ‘Your information and what you need to know’ leaflet with the person being referred, available via www.listening-ear.co.uk/privacy-policy*

Yes

Referring Agency

Contact Name

Job Title

Agency address

Contact number

Email

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

This field is hidden when viewing the form

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)

Do you have a known disability, health condition or neurodivergent condition?

Yes
No
Prefer not to say

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

Yes
No

Do you have a mental health difficulty, such as depression, schizophrenia, or anxiety disorder?

Yes
No

Do you have a physical disability or mobility issues?

Yes
No

Do you have a neurodivergent condition such as autism, ADHD, dyslexia, dyspraxia, dyscalculia, or tourette's?

Yes
No

Are you blind or have a visual impairment uncorrected by glasses?

Yes
No

Are you D/deaf or have a hearing impairment?

Yes
No

Do you 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 you

Have you received counselling/therapy in the past?*

Yes
No

If yes, do you feel you benefited from this:*

Have you accessed other Psychological services?*

Yes
No

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

Have you been diagnosed with any mental health condition?*

Yes
No

If yes, please give details below*

Have you ever received a Mental Health Assessment?*

Yes
No

If yes, please give details below*

Have you ever had thoughts of, or have you tried to harm yourself in any way?*

Yes
No

If yes, please give details below:*

Are you currently prescribed medication to help with psychological problems?*

Yes
No

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

Have you had any traumatic experiences that still affect you significantly now?*

Yes
No

If yes, please provide details on traumatic experiences:*

Are there any other Professionals working with you?*

Yes
No

If yes, please give details below:*

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

What do you consider to be your main difficulty?*

If you are referring for bereavement support, please state the date of the most recent bereavement*

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.

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

Most recent DASH score recorded?

Most recent MERIT score recorded?

Do you 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:*

Have you 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

Do you require an Interpreter?

No
Yes

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

How did you hear about our service?*

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

For VIDA (Occupational Health) Referrals, please provide:

Name of Employer

If school-based, please provide name school (for invoicing purposes)

Employee Payroll No

Purchase Order No

Counselling and Support Referral

Important

Third Party Referrals

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 you

For VIDA (Occupational Health) Referrals, please provide:

Counselling and Support Referral

Important

Third Party Referrals

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 you

For VIDA (Occupational Health) Referrals, please provide:

Subscribe