Referral – HOPE Bereavement Support

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Referral Form

Referral Form

Name

Email *

Date of Birth

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Ethnicity

Religion

Sexual Orientation

Primary Language

Interpreter RequiredYesNo

G.P.

Emergency Contact Name

Emergency Contact Phone Number

May we leave you a voicemail?YesNo

May we contact you via email?YesNo

May we contact you via post?YesNo

Type of referralSelf-referralHealth ProfessionalAdvocacyOther

Other type of referral

If you are completing this form on behalf of someone else, does the client consent to this referral?YesNo

Referral Agency Section

Name

Organisation Name

Job Title

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Contact Number

Email Address

Part 2

Are you currently experiencing any of these symptoms?DepressionAnxietyStressLow Mood/ SadnessTearfulNegative/ Bad thoughtsIntrusive/ Obsessive/ Compulsive thoughtsHopelessnessLack of sleep/ InsomniaSleeping too muchFatigue/ Low energy Thoughts of self-harmSuicidal thoughtsLoss/ GriefFearfulOverthinkingOvereating/ UndereatingLack of motivationInability to focusPlease tick all that apply

Other

Previous loss/ Bereavement History

If there is a history of pregnancy/child loss, are you pregnant again?YesNo

If so, please state the number of weeks gestation

Have you received any support/ treatment from psychotherapy/ mental health/ counselling services? Please include any current support arrangements

Preferred SupportFace to Face Counselling SessionsGroup Session / Befriender WorkshopsTelephone ConsultationsVideo Conferencing ConsultationsOnline SupportPlease note that the methods below are not guaranteed, individual needs will be assessed on a case by case basis by the team.

Do you consider yourself to have a disability or any additional needs? Please state any assistance requirements you feel you need so we can facilitate your referral/ appointment.

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Previously funded by

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Thank you to Leeds Clinical Commissioning Group and The Resourcing Racial Justice

Fund for enabling us to help the most vulnerable in our communities.

CIC Registration Number 12718396

BACP Organisational Membership Number 275755

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Home
About Us
Coaching
HOPE Trauma Work
Counselling
Support Groups
Workshops
Referral
Give
Press
Research
Our Policies
Contact Us