Referral Creation Wizard

Complete the following referral form to submit a request for counselling at South Bucks Counselling .

Client

Defaults to today’s date
Select title
Enter preferred name if applicable
Enter forename
Enter surname
Enter contact number
Enter house number and street
Enter town/city
Select country
Select county
Enter full postcode (e.g BT3 9DT or SW1A 1AA)
Enter an email address.
Enter date of birth
Select gender.
Select pronoun.
Select referral source (e.g Friend, GP, School, Self Referral etc)
Select person / organisation making the referral OR click '+' icon to add a new Referrer

 

Please select all presenting issues that apply
Please select a how did you hear about us option
Search and select your GP. Use the '+' icon below to add your gp if not found

 

Please provide brief details of why support is required.
Please tick box if you have previously had counselling
If you have used this service before, please give us some details on this.
Please provide details of days/time you are available
Please provide details of any medication, including dosage.
Please provide any additional information you feel relevant including any involvement with other mental health services

Preferences

Please select any special requirements you might need (Select all applicable).
Please select a location
Are ground floor facilities required?
If they are, please provide some detail regarding this.

Consents

How we use client information

The General Data Protection Regulation (GDPR) requires SBC to gain your explicit consent to hold your data. This data includes your contact details, information about your GP, your date of birth, address and other relevant personal information. We also collect diversity information, which we use in anonymised form via a unique reference number, to monitor the reach of our services.

 

Your personal data will not be shared with anyone outside South Bucks Counselling without your knowledge and permission, unless there is a legal requirement, a child or adult safeguarding issue, or a perceived risk of harm to yourself or another person. In some exceptional circumstances, for example if there is an immediate concern about your physical or mental health, we may need to contact your GP. Whenever possible, we would discuss this with you first.

 

South Bucks Counselling is accredited by the British Association for Counselling and Psychotherapy (BACP) and all our counsellors comply with the BACP’s Ethical Framework for the Counselling Professions. In accordance with their professional requirements, counsellors discuss their work with an external supervisor, but your identity is not revealed. Case material may sometimes be used anonymously by counsellors to enhance their practice and professional development. You can ask to see the information held about you at any time via a data subject access request, which will be responded to within 30 days. Your personal data is held securely for 7 years after you have finished counselling, and is then destroyed. 

Your responsibility

We would ask that you keep us informed (by email, telephone, or in writing) of any changes in your personal data so that we may have our records up to date at all times. If you wish to withdraw your consent please contact us (by email, telephone, or in writing). You have the ‘right to be forgotten’, which means you can request the deletion or removal of personal data where there is no compelling reason for its continued processing.


GP/3rd Party Consents

I consent to having my information held as outlined above and confirm that I have given South Bucks Counselling permission to refer, in respect of my counselling, to my doctor or any other health professional involved in my care.

Why does South Bucks Counselling need this? In some exceptional circumstances, for example if there is an immediate concern about your physical or mental health, we may need to contact your GP for your own safety.
Whenever possible, we would discuss this with you first. We do not discuss details of the conversations you have with your counsellor with your doctor.
Please note that without this consent we cannot proceed with your application. If you have any questions about consent, please contact us on 01494 440199.

Communication Consents

Tick your preferred methods of consent from the list below. Please TICK ALL that apply (a minimum of one must be selected)

I consent that you can contact me by email

I consent that you can contact me by phone and you can leave voice messages, in order to arrange an assessment appointment

I consent that you can contact me by SMS texts

I consent that you can contact me by letter