Referral Submission

Please take a moment to fill out the below form. Once submitted, a therapist will be in touch to discuss further assessment. Please note, CYP (children and young people) are considered C - 4-10 YP - 11-25. Referrals can be made directly by anyone over the age of 16.

Please note, spaces available to subsidise costs are often limited due to funding needs, however it is our ongoing commitment to securing funding which will allow for more support to be offered.

'Subsidised cost' suggests a low cost fee for services (eg; £20), with the remainder paid for by funding or donations. Costs to subsidise vary depending on the service or activity provided. Any donations received are returned into the Service to enable more low-cost sessions for those seeking support.

All referral forms are processed and will be followed up with an assessment either over the phone or via email link within 7 working days. For referee's under 16 years of age, the named referrer will be considered the main contact. Parental permission is required for any referee 16 or under.

When completing the referral form, referees are agreeing to details of referral to be shared with the EKC network of therapists in order to find a suitable, available service provider. Please ensure you have permission or have informed referred persons of the process.

Full Name (referer)

Telephone number (referer)

Relationship to person in need

Full Name (person requiring support)

Date of Birth (of person requiring support)

Postcode (person requiring support)

Contact number (of person requiring support - please add parent/carer/guardian if under 18 years old)

Is the person being referred a Child in Care (CiC)?

Does the person requiring support have any diagnosed learning difficulties or specific Mental Health diagnosis? Please state

Does the person being referred have any ongoing support by NHS funded services or Social Services? Please give details *

Brief description of concerns requiring therapeutic intervention

Is the rerrered person currently in counselling or has previously received counselling? Please give details. this may include waitlist for therapeutic services with other organsiations and/or assessments. *

Thank you. Referrals with be reviewed within 72 hours and relevant contact made.

In submitting this form, it is agreed that all parties may be contacted for further information and/or assessment. It is required that referees are informed of referrals.

Connect

East Kent C.I.C

Connecting to Accessible Mental Health Support

Referral Submission

In submitting this form, it is agreed that all parties may be contacted for further information and/or assessment. It is required that referees are informed of referrals.