Referral Creation Wizard

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

Privacy Statement
Nexus processes personal information provided through this form for the purpose of managing your referral and providing counselling services. Your information will be handled securely and confidentially in accordance with data protection legislation and the Nexus Privacy Policy.

Consent
By submitting this form, you consent to Nexus processing and storing your information for the purpose of progressing your counselling referral and any subsequent service you receive.

Following referral form submission, a member of the Nexus team will contact you to process your referral. Please be aware that calls from Nexus will display as a private or withheld number.

We will make up to three attempts to contact you. If we are unable to make contact, you will be given a final timeframe to respond. If we do not hear from you, your referral will be closed due to no contact and you will need to submit a new referral form if you wish to access counselling services in the future.

Professional / Third-Party Referrals
If you are submitting this referral on behalf of someone else, please only continue if you have obtained the client's consent to make the referral and share their information with Nexus.

Confirmation
By submitting this form, you confirm that you have read and understood the information above and consent to Nexus processing your information for the purposes of managing your counselling referral.

Self-Referral: I confirm that I have read and understood the Privacy Notice and consent to Nexus processing my information for the purposes of this referral.

Third Party Referrals: I confirm that I have obtained the client’s consent to submit this referral on their behalf, to share the information provided with Nexus, and for Nexus to contact them directly regarding their referral.

 

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 with a space (e.g. BT3 9DT or SW1A 1AA). Use the 'i' icon for more examples.
Enter an email address.
Enter date of birth
Select gender.
Select pronoun.
If under 16 enter name and contact number
Enter name of school
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 secondary issues that apply
Please tick box if you have previously had counselling
If you have used this service before, please give us some details on this.
If yes, please tick the box below
Select abuse type.
Please provide details of any medication, including dosage.
Please select an option.
Yes No
Please enter some details on which language.

 

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

 

Briefly why support is needed.
Days and times available.
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
Please select a project and ensure you are eligible otherwise your referral may be cancelled.
Please select a service.
Are ground floor facilities required?
If they are, please provide some detail regarding this.

Family Members / Contacts

Contact Information

Tick if this contact may attend appointments.
Select title.
Enter forename.
Enter surname.
Enter preferred name if applicable.
Enter email address.
Enter date of birth.
Select the contacts relationship.
Select gender.
Enter 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 full postcode with a space (e.g. BT3 9DT or SW1A 1AA). Use the 'i' icon for more examples.
Please enter a valid postcode
Clear
  • No records assigned.

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.


GP/3rd Party Consents

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

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?

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 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