Patient Referral Form: Referrers Contact Details Referrer Name: Referrer Email: Referrer Telephone: Referrer Address: Patient Details Patient Name: Patient Date of Birth: Patient Email: Patient Telephone: Patient Address: Emergency Contact Name: Emergency Contact Telephone: GP Details Name: Telephone: Address: Has a referral been made to any other service for counselling i.e. Hull Talking Therapies or East Riding Talking Therapies?: YesNo You will receive a response from that provider shortly to book in for an assessment. At assessment if appropriate you can ask for the referral to be allocated to House of Light. This may not always be possible. Any questions around this, please do not hesitate to contact our team on 01482 580499. Other relevant contacts or services involved Medication: Alcohol misuse: YesNo Safeguarding issues: YesNo Risk to self/others:LowMediumHigh Drug misuse: YesNo History of suicide/self-harm: YesNo Client consent to referral: YesNo Reason for referral: Consent data storage: YesNo Consent to contact GP, Midwife, Health Visitor: YesNo
