Referral Creation Wizard

Complete the following referral form to submit a request for counselling at Hammersmith, Fulham, Ealing & Hounslow Mind .

Privacy Statement

Hammersmith, Fulham, Ealing & Hounslow Mind processes identifiable personal data for the purpose of maintaining the operations of its business. Any personal data you provide to Hammersmith, Fulham, Ealing & Hounslow Mind through any means, verbal, written, in electronic form, and through the Hammersmith, Fulham, Ealing & Hounslow Mind website, will be held and processed in strictest confidence, only in relation to purposes relevant to your request, and in accordance with the Data Protection Act 2018, and the Hammersmith, Fulham, Ealing & Hounslow Mind Privacy Policy.

Client Consent Form

By signing this document, you give Hammersmith, Fulham, Ealing & Hounslow Mind consent to process and store your information in relation to your request for counseling from our service, and any subsequent counseling service you may receive from Hammersmith, Fulham, Ealing & Hounslow Mind.

If you do not enter into a counselling contract with Hammersmith, Fulham, Ealing & Hounslow Mind we will securely destroy these forms after 2 years.

If you proceed to engage with the service and attend an assessment and counselling sessions, then we will retain your records (including the intake form) for 7 years after you complete your counselling contract. After this time your records will be securely destroyed. To destroy records, we shred all hard copies and destroy electronic copies through specialist contractor.

All information you provide us is processed and stored as securely as possible. Our hard copies are always stored in locked cabinets with limited access, and our electronic records are password protected and stored in a secure server. Any information exchanged via email is always encrypted and emails are destroyed immediately afterwards. Unfortunately, internet communication is never completely secure, and for this reason we do our best to ensure we abide to highest standards of data protection. We ask you to recognize that any transmission of information you communicate to us over email is at your own risk. Once we have received your information, we will proceed to store it safely in order to prevent unauthorized access.

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)

 

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

 

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.

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 (e.g BT3 9DT or SW1A 1AA)
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

Our data is sent anonymously to the NHS so they can track mental health statistics. The data is used to inform service improvements, monitor service performance, client intervention,
patient experience and treatment outcomes. Please tick if you hare happy to share with 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