Health Professional Bereavement and Loss Counselling Referral Form

If the person you are referring requires immediate support please call their GP, call the Camden and Islington crisis line on 0800 917 3333, or assist them to call Samaritans on 116 123 or to visit their local Accident & Emergency department
Please provide as much information as possible so we can process your referral efficiently. If you are unsure if our service is the right service for your client or if you have any problems completing this online form, you can call us to discuss this.
Please Note:- We are not able to accept referrals for bereavements that happened less than 8 weeks ago. We can only take referrals for people over 18.

Fields marked with * are required

Referrer Details

Client Details

ESSENTIAL; Referral cannot be accepted without this

GP Details

Please note, we can only accept referrals for our funded counselling service for clients registered with a GP in Camden and Islington, or NHS or social care staff working within North Central London.

Details of Bereavement/Loss

Emergency Contact

Please add details of who your client would like us to contact in the event of an emergency
Please note we would only use this information in the event of an emergency

Further Details

Please note we do not work with interpreters in counselling sessions. We do have some capacity to offer counselling in other languages. Please give details of your clients preferred language:

Referral Reason

We need to book an assessment appointment before counselling can begin, please check with your client and tell us when it is most convenient for them to have this one-off appointment. This appointment will be booked in advance after a brief telephone conversation.
Submitting this information confirms that you have consent from your client to share their details with us, and for us to store it electronically.