Health Professional Referral

For Bereavement and Loss Counselling

For clients living or working in Islington

Please read before making a referral:

CCIWBS receives funding to provide free bereavement counselling for people aged 18 and over who live or work in Islington.

This funded service offers up to 10 sessions of one-to-one counselling, providing a safe, confidential and consistent space for clients to reflect and explore their feelings with a volunteer bereavement counsellor. Sessions are 50 minutes and clients need to be able to commit to the same day and time every week.

This service is not suitable for people in need of urgent support or in crisis.

In submitting this referral,

I understand that this funded service offers up to 10 free one-to-one counselling sessions. I confirm that this person is not in crisis or in need of urgent support. I confirm that I have discussed this referral with the person and have their consent to share their details with CCIWBS. The person feels comfortable accessing counselling in English.

Referrer Details

Referrer name *

Job title *

Organisation *

Contact e-mail address *

Contact phone number *

Referral type

Referrer type *

Client Details

Fields marked * are required. The person being referred must be aged 18 or over.

Title *

First name *

Last name *

NHS Number *Essential: the referral cannot be accepted without this.

Date of birth *

Gender *

Address line 1 *

Address line 2

Borough *

Postcode *

Mobile Phone Number *

Client has given permission to leave voicemail on mobile? *

YesNo

Client has given permission to send SMS text reminders? *

YesNo

Client's Home Phone Number

Client has given permission to leave voicemail on landline?

YesNo

Email address

No client email?The client does not have an email address

GP Details

GP surgery *

Address of GP surgery *

GP surgery phone number

Details of Bereavement/Loss

Most recent bereavement/loss and/or relationship to client *

Date of death/loss *

Choose “Unknown” where the month or year is not known.

Cause of death/loss *

Additional recent losses

Please provide details of any other recent additional losses or bereavements (for bereavements please provide - month/date of each bereavement; Relationship of deceased to client and cause of death).

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 help from other services? *

YesNo

If yes, please give details

If you have already referred the client to NHS Talking Therapies, we cannot accept this referral.

Medical and Mental Health Information

Are they prescribed any medication for their mood? *

YesNoUnknown

If yes, please give details

Any long-term medical conditions? *

If yes, please specify

Any current or past mental health diagnosis? *

YesNo

If yes, please specify

Please specify any additional accessibility information

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

Relevant previous history, including treatment, self-harm, previous suicide attempts, forensic history or safeguarding issues

Further Details

Please provide the following additional details about the client.

Nationality *

Ethnicity *

Sexuality *

Does the person feel comfortable about accessing counselling in English? *

YesNo

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

YesNoDon't know

Submitting this form sends the referral securely to CCIWBS for review.