Referring Into Cygnus

We are open Monday - Friday from 9am - 4:30pm, with our last counselling appointment starting at 3:30pm.

PLEASE ONLY COMPLETE OUR ONLINE REFERRAL FORM IF YOU ARE AVAILABLE TO ATTEND COUNSELLING SESSIONS DURING THESE TIMES.

We are a small charity with a dedicated team of staff and volunteers and are unable to offer appointments outside of these times.

This form can be used to refer yourself into our service. Professionals may also use this form to refer clients into our service.

For professionals: Before completing this form, please ensure your client is aware of this referral and has understood the data protection policy relating to the sharing of personal information.

When we receive this referral form, we will contact the client to explain what personal information we have, where it came from and how we will process it. We will also send out our assessment pack to be completed and returned to us via email, post (SAE will be provided) or in person.

The client will have 21 days to return this to us.

If we do not hear from the client, we will assume they no longer wish to access the service. Whilst the client is on our waiting list, we cannot accept any responsibility for their wellbeing or safety.

If you need any assistance in filling out this form please don't hesitate 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