Private Counselling & Therapy Sessions - Listening Ear Merseyside

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. Children’s Christmas Party, Memorial Service or Health & Wellbeing activities)

Yes

Client's details

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)

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

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

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

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

If other, please state:

Gender

Prefer to self-describe Gender (please state)

Is gender the same as that assigned at birth?

Pronouns

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 impairment, health condition or learning difference?

Yes
No

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 impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches?

Yes
No

Do you have a social/communication impairment such as a speech and language impairment or Asperger’s syndrome/other autistic spectrum disorder?

Yes
No

Do you have a specific learning difficulty such as dyslexia, dyspraxia, or AD(H)D?

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 an impairment, health condition or learning difference 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?*

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

What do you consider to be your main difficulty?*

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:*

How did you hear about our service?*

For VIDA (Occupational Health) Referrals, please provide:

Name of Employer

Terms & Conditions

Listening Ear will provide a free assessment. Subject to meeting the criteria for our services, sessions will then be charged at £100 per 50 minute session, payable in advance in blocks of three (£300). Following receipt of payment, Listening Ear will contact you to arrange sessions at a mutually convenient time. Clients who do not attend a session or cancel a session without giving Listening Ear 24 hours notice will be liable to pay for these sessions.

I agree to the above terms and conditions*

Yes

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

If someone other than the client is paying for these sessions, please provide the payee contact details below.

Name

Address

Phone

Email

Name

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