Referral Form - HiS Charity

1Tell us about yourself

2Why you are referring

3Medical background

Are you making this referral for yourself?
- Yes - for myself
- No - I am a third party
Please note that if you are a third-party organisation you will need to send us an email with further information about your client. Also when referring someone there is a minimum £15 donation towards counselling. Due to popular demand on our service, we regret to inform you that there is now a waiting list for processing new referrals. Unfortunately this can be anything up to 4 or 5 months. If you are happy to wait that long, then please go ahead and make the referral. Once again we are deeply sorry that we can not help you sooner. Please contact MIND or the CRISIS team in your area if you need help. Kind regards Jules CEFO of HIs Charity
Third party
Third party name*
First Last
Third party phone
Third party email*
About you
Name*
First name Last name
Your address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Phone*
Email*
Date of Birth*
DD slash MM slash YYYY

Medical background
Current Medication*
Relevant physical conditions*
Do you smoke?*
- Smoker
- Non-smoker
Ethnicity
First Language*
Ethnicity
Next of Kin (optional)
Relationship
Name
First Last
Phone
Your GP (optional)
GP Name
GP Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
GP Phone
Consent
I consent for you to contact my GP
Finally ...
Further notes
Many thanks for your referral. Someone from the team will give you a bell . There is a 6 weeks assessment process, however in the meantime please use our 24/7 helpline, where you will be put through to a professional counsellor.
How urgent is your referral?*
On a scale of 1 (low) to 10 (high), how urgent is your referral

Third party