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 currently 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.

Once a referral has been submitted, you will receive a confirmation message on the screen to confirm that it has been received. One of the team will then be in touch with you/your client to carry out a Triage/Assessment; please note: due to the volume of referrals we are processing, this could take a number of weeks.

Important information: It’s really important to keep us updated with any changes to your contact details once you’ve made your referral, therefore please get in touch if you change your phone number. Unfortunately, if we cannot contact you we are unable to hold appointments open for you when we have other people on our waiting list, and you will be discharged from our service if:

We make two attempts to contact you/the client to complete triage/assessment and are unsuccessful
If you do not turn up for an appointment without contacting us and we are unable to get in touch with you
If you do not attend two or more appointments

This does not mean that you cannot access our service in the future, however, you will need to make a new referral into Cygnus.

Whilst you/the client is on our waiting list, we cannot accept any responsibility for your/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

Today's date

What Service is Required? * Counselling
Bereavement Counselling
Bereavement Group
Other (please specify)

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

Title

First Name *

Last Name *

Address *

Town *

Postcode *

Date of Birth *

Age *

Safe Telephone Number *

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

Email *

In addition to telephone what are your/the clients’ other preferred methods of contact? (Please select all that apply) * Letter
Text
Voicemail
Email

Have you/the client accessed Cygnus Support before? *

Additional Information

Is the referral a Young Person?

GP Practice *

GP Name

Location

Telephone Number *

Referrer's Details

Name *

Organisation / please use your own details if you are self-referring *

Address *

Town *

Postcode *

Contact Number *

Email address *

How Did you hear about Cygnus Support? *

At times it may be necessary for another worker within the referring organisation to request information or updates about you/the client – are you/the client happy for us to share information with anyone within the referring organisation?*

Do you give your permission for us to share information about you with a parent/guardian?*?

If you answered yes to the question above please give details of the parent/guardian below:

Name

Their relationship to you

Their contact telephone number

Why do you/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 – please select the days of the week you are available. *

Please note: we will try to accommodate sessions within your selected days wherever possible – we would ask you to be as flexible as possible because if you have limited availability this might mean you have to wait longer.

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred counselling delivery*

Do you/the client have difficulty using stairs? *

Would you/the client prefer a Male or Female counsellor?*? *

Are you/the client currently working? *

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

By completing this form you are confirming that you have read and understood the above message, and that you are giving consent for your information to be kept and stored by Cygnus Support in line with GDPR and our Privacy Policy. Visit https://www.cygnussupport.com/privacy-policy/ for our privacy policy or alternatively you can request one via email at admin@cygnussupport.com

[*] denotes a required field

Cygnus Support, 1 Council Rd, Ashington, Northumberland, NE63 8RZ

(01670) 853977