Please complete this form to refer yourself 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 people who are receiving psychological support from another counselling or mental health service. Our service is not suitable for people with untreated alcohol or drug dependence.
We are not a crisis service. If you are at risk now, call 999 or go to A&E. You can call Samaritans free, day or night, on 116 123.
Your full name *
Your address *
Phone number *
Email address
Which ways can we contact you? Tick all that apply. *
PhoneEmailLetter
Which do you prefer? —Please choose an option—PhoneEmailLetter
Age *
Gender identity
Ethnic identity
Do you have any language needs? *
In addition to English, we can offer counselling in Bengali, Sylheti and Greek.
YesNo
If yes, please describe
Do you have any mobility issues? *
We can only accept your referral if you give us your GP's details.
Name of GP or GP practice *
GP address *
GP phone number *
Name *
Do you have a psychiatric diagnosis? *
If yes, please give details
Are you being seen by any other mental health or counselling service? *
Their name
Their relationship to you *
Date of death
Cause of death
Place of death
Their age when they died
Have you lost your role as a carer? *
Have you lost your carer? *
Are you currently a carer? *
Is there anything else you would like us to know?
Please leave this field empty.
I consent to CELBS holding my personal information in line with our privacy policy.
