Self-Referral

For Bereavement and Loss Counselling

Please complete this referral form if you would like to access our low-cost counselling service. All fields marked * are required fields.

Please note that we are not an emergency crisis service. If you are in crisis, or at risk of suicide or harm, contact your GP or call NHS 111 and select option 2 for the Mental Health Crisis Team. If there is an immediate risk, call 999 or attend A&E.

I am making this referral for myself. I understand that fully funded counselling spaces are limited and that I will be asked to make a contribution towards the cost of assessment and counselling. Contributions range from £25 to £60 per appointment.

I can commit to 50-minute weekly sessions on the same day and time each week for the duration of the counselling contract (up to 10 weeks for funded spaces, up to 6 months for contributing clients). *

Yes No

This is a short-term counselling service and counsellors providing this service are volunteers who may be qualified counsellors or counsellors in training. I am aware that there may be circumstances where this service may not be suitable to meet my needs.

How did you hear about us? *

If other, please tell us how

Your Details

Fields marked * are required. You must be aged 18 or over.

Title *

First name *

Last name *

Date of birth *

Gender *

Address line 1 *

Address line 2

Borough *

Postcode *

Mobile Phone Number *

Permission to leave voicemail on mobile? *

YesNo

Permission to send SMS text reminders? *

YesNo

Home Phone Number

Permission to leave voicemail on landline?

YesNo

Email addressProviding contact details means you consent to being contacted by us.

No email address?I do not have an email address

GP Details

Counselling is confidential. We do not share information with third parties without explicit written consent, except where our duty of care requires disclosure because there is a risk of harm. Wherever possible, we take such steps in consultation with you. You must be registered with a GP to access counselling.

GP surgery *

Address of GP surgery *

GP surgery phone number

Details of Bereavement/Loss

Your most recent bereavement/loss and/or relationship to you *

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; their relationship to you and cause of death).

What do you hope counselling will help you with?

Please tell us about any other support or counselling you currently receive, or any waiting lists you have joinedFor example: a mental health team, private therapy or NHS Talking Therapies.

Is there anything else you would like us to know at this stage?

Further Information

These questions help us make the service accessible and meet any specific requirements.

Nationality *

Ethnicity *

Sexuality *

Do you feel comfortable accessing counselling in English? *

YesNo

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

YesNoDon't know

Contribution towards cost of counselling

Please fill in this section if you want to access our low-cost counselling service.

I agree to make a contribution towards the cost of counselling of between £25 to £60 per session depending on my financial status. *

Yes - I can contribute between £25 and £60 per appointment. No - I would like to apply for a fully funded counselling space. These spaces are limited and depend on grants and donations.

Contribution per appointment * Read more about counselling costs (opens in a new window).

Briefly describe your circumstances if you are applying for a fully funded counselling spaceRead about funded counselling spaces (opens in a new window).

What happens next

The information you provide will be stored for six years. Submitting this form confirms your acceptance of our data storage procedure.

For more information, read our confidentiality and data-sharing information (opens in a new window).

You can expect a first call within 7â€“10 working days to discuss the service, your requirements and any queries you may have.

After this call you will be booked in for an assessment appointment. Assessment appointments are 50 minutes long and available over the phone or in person.

There will be a further waiting time after the assessment to the counselling start depending on availability and individual requirements. This typically varies between three to eight weeks but may be longer.

If at any stage we have concerns about whether we are able to offer suitable counselling support to you, this will be explained to you and you will be sign-posted to other potentially suitable services or organisations.

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

Your Details

GP Details

Details of Bereavement/Loss

Medical and Mental Health Information

Further Information

Contribution towards cost of counselling

What happens next