Referral Creation Wizard

Complete the following referral form to submit a request for counselling at Nexus NI .

Client

Personal Information

Enter the client's forename.
Enter the client's surname.
Enter a contact number for appointments.
Enter a landline number.
Enter an email address for appointments.
Enter the current school being attended if applicable.
Please tick if you have previously seen one of our Counsellors?
If you have used this service before, please give us some details on this.

 

Please enter the client's date of birth (format: dd/MM/yyyy)
If client is under 16, please enter a parent/guardian's name and contact number.
Please select the clients gender.
Please select the clients pronoun.
Please select a how did you hear about us option

Address Information

Enter a street and house number.
Optionally enter a town.
Optionally, select a country.
Optionally, select a county.
Enter the first part of the postcode (e.g MK6)
Enter the second part of the postcode (e.g 5LP)

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.
Please select a project below. Please make sure you are eligible otherwise your referral may be cancelled.
Please select a service.
Who told you to make a counselling request? If you are a professional making a referral please enter where you are from.

Issues

Please give a brief summary of why support is required (including any relevant medical/family history).
Please give a brief summary of when you are available.
Please select the an abuse type.
Select one or more of the issues you are experiencing.
Please enter some additional information.
If yes, please tick the box below
Please select an option.
Yes No
Please enter some details on which language.

GP and Referrer

General Practitioner Details

Please select an existing GP from the list below.
If your general practitioner doesn't exist in the list above tick this checkbox and complete the new GP form.

Referrer Details

Please select an existing referrer from the list below.
If your referrer doesn't exist in the list above tick this checkbox and complete the new referrer form.

Family Members

Contact Information

Tick if this family member may attend appointments.
Enter family members forename.
Enter family members surname.
Enter family members email address.
Enter family members date of birth.
Select the family members relationship.
Select the family members gender.
Enter family members contact number.
Please enter a contact number

Address Information

Tick if you would like to copy the address from the primary client.
Enter a street and house number.
Please enter a street
Optionally enter a town.
Please enter a town
Select a country
Please select a country
Select a county
Please select a county
Enter postcode area.
Please enter an area code
Enter postcode.
Please enter an postcode
Clear
  • No family members added.

Consents

How we use client information

We may use client information to carry out our obligations arising from any contracts entered into by the client and us. We promise to keep your details safe and secure. We will not share your information with third parties for marketing purposes. We may contact you to let you know about other services, events or for evaluation purposes.

The circumstances when details can be shared include:

  • When a counsellor has good grounds for believing that a person may cause serious harm to themselves or others.
  • When we are instructed by a court to disclose information.
  • When a person discloses criminal activity, or knowledge of criminal activity, this includes statutory obligations.
  • When it is necessary to uphold child protection laws.

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.


NHS Permission

Our data is sent anonymously to the NHS so that they can track mental health in our area. The data set is used to inform service improvements and monitor service performance,
clinical interventions, patient experience and treatment outcomes. Are you happy for your data to be sent to the NHS?

Access permission

I consent that you can share details with my GP and other 3ʳᵈ parties who are involved in the contract entered into by you and us

Communication Permission

I consent that I'd like to hear from you via email

I consent that I'd like to receive phone calls from you and you can leave voice messages

I consent that I'd like to receive SMS texts from you

I consent that I'd like to receive letters from you

Leave unchecked and we will not contact you via this method, a minimum of one consent must be given.