CCIWBS Self Referral 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 (020 3317 6333), 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.

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 www.bereavement-counselling.org/copy-of-terms-of-use

Fields marked with * are required

Title:*

First Name:*

Last Name:*

NHS Number:*

ESSENTIAL; Referral cannot be accepted without this

You can only refer yourself to us if you are over 18

Date of Birth:*

Gender:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Mobile Phone Number:*

Permission to Leave Voicemail on mobile?:*

Yes

Permission to send SMS Text reminders?:*

Yes

Home Phone Number:

Permission to leave voicemail on landline?:

Yes

Email Address:*

Providing us with your contact details means you are consenting to be contacted by us.

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

GP Surgery:*

Do you*

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?

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 £15 to £60 per session depending on my financial status. *

Yes (details will be discussed at assessment)

No, I would like to apply for funding through the service’s extreme hardship fund.

Please give a brief description of your circumstances if you want to apply for the extreme hardship fund:

Contribution: *

Deceased person/s (or loss') relation to you:*

Date of death/s (or Loss):*

Cause of death/s:*

Which type of counselling support are you looking for?:*

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

Three-Session Early Intervention Support
To provide support after a sudden and unexpected death

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

Please describe what support for your bereavement or loss would be helpful for you:*

We ask these questions to ensure that our service is accessible to everyone and to ensure any specific requirements are met.

Nationality:*

Ethnicity:*

Sexuality:*

Do you have any long term medical conditions?:*

Yes

If yes, please specify:

Do you have any mental health conditions?:*

Yes

If yes, please specify:

Are you currently taking any prescribed medication:*

Yes

If yes, please specify:

Do you have any disabilities you would like us to be aware of?:

None

Hearing

Memory, ability to concentrate (learning disability)

Mobility

Sight

Speech

Other

If Other, please specify:

Are you receiving counselling, therapy or other mental health support elsewhere?:*

Yes

Unsure

If yes, please provide further details:

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 8 to 10 weeks long.

When you click here to SUBMIT please note that you are agreeing to our Data Storage Procedures.

Self-Referral
For Bereavement and Loss Counselling

Your Information

Your Details

GP Details

Contribution towards cost of counselling

Details of Bereavement/Loss

Further Information

Self-Referral For Bereavement and Loss Counselling

Your Information

Your Details

GP Details

Contribution towards cost of counselling

Details of Bereavement/Loss

Further Information

Self-Referral
For Bereavement and Loss Counselling