Referring into Cygnus (Guidance and Referral Links)

Please fill out the form below to refer into Cygnus. If you need any assitance in filling out this form please don't hesitstate to contacts us on:

01670 853977 or email: admin@cygnussupport.com

Date of Referral *

Date Received

What Service is Required? * Counselling
Course/Bridge/Other (please give details overleaf)

Client Details (In the case of a self-referral your details)

Title

First Name *

Last Name *

Address *

Postcode *

Date of Birth *

Age

Safe Telephone Number *

If someone else answers the phone, who should we say we are?

Email *

Preferred Method(s) of Contact? * Letter
Text
Voicemail
Email

Has the client accessed Cygnus Support before?

Additional Information

Is the referral a Young Person?

GP Practice *

GP Name

Location

Telephone Number *

Referrer's Details

First Name *

Last Name *

Organisation/Self-Referral *

Address/Location

Contact Number *

How Did you hear about Cygnus Support? *

Why does the client need counselling now? *

What other services are involved with the client? *

Children or Adult Social Care

Child & Young People Service

Community Mental Health Team or Talking Matters

Crisis Team

Addiction Services

Police or Probation

Victim's First

Other (please specify)

Risk Assessment and Management Details *

Known Risks

Staff or Public

How is this managed?

Self

How is this managed?

Children

How is this managed?

Other Service Users

How is this managed?

Additional Information - Client Needs

Availability for appointments? *

(Our opening hours are 9:00am – 4:30pm and our last counselling appointment is at 3:30pm. We can sometimes offer evening and Saturday sessions this is dependent on counsellor availability.)

Monday

Tuesday

Wednesday

Thursday

Friday

Where can the client travel to? *

Does the client/do you have difficulty using the stairs? *

Male or Female counsellor? *

Is the client working? *

Is there anything else you think we need to know? Does the client have any additional needs / learning difficulties? Please indicate if the client will need support to complete our assessment pack.

[*] denotes a required field