Self-Referral Bereavement and Loss Counselling Form

If you are in an emotional or mental health crisis and you need immediate support, please call your GP, the Camden and Islington Crisis Team (0800 0234 650), Samaritans on 116 123 or go to your local Accident & Emergency department.

Please provide as much information as possible to help us process your referral quickly.

If you are unsure if our service is the right service for you or if you have any problems completing this form, you can call us to discuss this.

Please note – if your bereavement happened less than 8 weeks ago, we cannot accept your referral.

Your Information

Before CCIWBS can process your referral, we need to tell you what happens to your data. At CCIWBS we have a confidential in-house database where we store your data and clinical notes. If your GP is in Camden or Islington, we also need to add your data to the NHS England database where it is stored under your NHS number, to help commissioners evaluate our service. We will also add your weekly questionnaires (but not your clinical notes) to the 'iaptus' database.

This also helps us to see how clients move between different services in our partnership eg Age UK Camden and iCope.

Please be aware that the information you share with us is kept confidential. However, if you share information concerning current or potential harm to yourself or another person, it is likely that we will need to inform other agencies to ensure that the right support is provided. We would always try to contact you first to discuss this.

The information you provide will be stored for five years and completion and submission of this form will be considered your acceptance of our data storage procedure.

For more information about confidentiality and data sharing please see

Fields marked with * are required

Your Details

ESSENTIAL; Referral cannot be accepted without this
You can only refer yourself to us if you are over 18
Providing us with your contact details means you are consenting to be contacted by us.

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 let us know if there is anyone you 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 Information

We ask these questions to ensure that our service is accessible to everyone and to ensure any specific requirements are met.
We need to book an assessment appointment before counselling can begin, please tell us when is most convenient to have this one-off appointment. This appointment will be booked in advance after a brief telephone conversation.
Thank you for taking the time to complete this form. Please note, you will receive an email confirmation after submitting this form where you will be asked to confirm your email address. We will then be in touch with you as soon as possible to book an appointment for a counselling assessment. Please note our waiting list is currently 12 weeks long.
When you click here to SUBMIT please note that you are agreeing to our Data Storage Procedures.