CCIWBS Referral Form

CCIWBS is not a crisis service.
If the person you are referring is in crisis, please call one of the numbers below based on your area.

Camden & Islington
Crisis Team Tel: 020 3317 6333
Camden GP Hub Tel: 020 7391 9979
Islington GP Hub Tel: 0203 859 4959

or assist them to call Samaritans on 116 123 or visit their local A&E 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 can only take referrals for people over 18.

Fields marked with * are required

Referrer name:*

Job Title of Referrer:*

Referrer organisation:*

Contact e-mail address:*

Contact phone number:*

Title:*

First Name:*

Last Name:*

NHS Number:*

ESSENTIAL; Referral cannot be accepted without this

Gender:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Mobile Phone Number:*

Client has given permission to Leave Voicemail on mobile?:*

Yes

No

Client has given permission to send SMS Text reminders?:*

Yes

No

Client's Home Phone Number:

Client has given permission to leave voicemail on landline?:

Yes

No

Email Address:*

We receive limited, annual funding for clients in the boroughs of Camden and Islington. Please note that if your client is not in these boroughs or the waiting list has been closed, clients can still access our service via our low-cost counselling service.

Does the client *

have a GP in Camden or live or work in the borough of Camden,

have a GP in Islington or live or work in the borough of Islington,

have a GP in another borough?

GP Surgery:*

GP Name:

Deceased person/s (or Loss) or relation to client:*

Date of death/s (or Loss)
Please provide month and year of death:*

Cause of death/s:*

Which type of counselling support is the client looking for?:*

One-to-one counselling
Please note that we cannot accept your referral if the bereavement happened less than 6 months ago.

Bereavement Group Counselling
Please check our website to find out about the dates of our next group.

Nationality:*

Ethnicity:*

Preferred Language:

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:

Sexuality:*

Does the client have any disabilities or special access requirements? e.g. visual impairment, hearing difficulties, mobility issues:

Yes

No

Unknown

If yes, please specify:

Any long term medical conditions?:*

Yes

No

If yes, please specify:

Any mental health conditions?:*

Yes

No

If yes, please specify:

Are they an NHS or social care member of staff working in North Central London?:*

Yes

No

Don't know

Reason for referral (please give a full and complete reason for referral, including existing and historic mental health diagnoses, interventions already tried and response to these):*

Is the person receiving any help from other services?:*

Yes

No

If yes, please give details:

Are they prescribed any medication for their mood?:*

Yes

No

Unknown

If yes, please give details:

Please give full details of any CURRENT risk to self or others, CURRENT risk from others, safeguarding issues, substance misuse:

Relevant PREVIOUS history including treatment, self harm, or PREVIOUS suicide attempts, forensic history or safeguarding issues:

Health Professional Referral
For Bereavement and Loss Counselling

Referrer Details

Client Details

GP Details

Details of Bereavement/Loss

Further Details

Referral Reason

Health Professional Referral For Bereavement and Loss Counselling

Referrer Details

Client Details

GP Details

Details of Bereavement/Loss

Further Details

Referral Reason

Health Professional Referral
For Bereavement and Loss Counselling