Please use this form to refer a client to CELBS. Questions marked * must be answered.

Who we can help. We offer counselling to residents of the City of London and the London Borough of Tower Hamlets, and to anyone who has lost a loved one in one of the Barts Trust hospitals (Royal London, Whipps Cross, Newham, Barts or Mile End).

We are unable to offer counselling to clients who are receiving psychological support from another counselling or mental health service. Our service is not suitable for clients with untreated alcohol or drug dependence.

About you (the referrer)

Your name *

Organisation *

Job title *

Address

Phone number *

Email address *

Client contact details

Client's full name *

Client's address *

Client's phone number *

Client's email address

Which ways does the client consent to being contacted? Tick all that apply. *

PhoneEmailLetter

Which do they prefer?
—Please choose an option—PhoneEmailLetter

About the client

Age *

Gender identity

Ethnic identity

Does the client have any language needs? *

In addition to English, we can offer counselling in Bengali and Sylheti.

YesNo

If yes, please describe

Does the client have any mobility issues? *

YesNo

If yes, please describe

Client's GP

We can only accept the referral if you give us the client's GP details.

Name of GP or GP practice *

GP address *

GP phone number *

Client's emergency contact

Name *

Phone number *

Client's health and history

Does the client have a psychiatric diagnosis? *

YesNo

If yes, please give details

Is the client currently seeing a psychiatrist? *

YesNo

If yes, psychiatrist's name

Psychiatrist's address

Psychiatrist's phone

Psychiatrist's email

How often does the client see the psychiatrist?

Is the client being seen by any other mental health or counselling service? *

YesNo

If yes, please give details

Does the client have a history of violence or aggression towards others? *

YesNo

Does the client have a history of alcohol, drug or substance misuse? *

YesNo

If yes to either, please give details

About the person who died

Their name

Their relationship to the client *

Date of death

Cause of death

Place of death

Their age when they died

Caring

Has the client lost their role as a carer? *

YesNo

Has the client lost their carer? *

YesNo

Is the client currently a carer? *

YesNo

Is there anything else we should know?

Please leave this field empty.

The client knows about this referral and agrees to CELBS holding their personal information in line with our privacy policy.