Date Referral Received
Client ID
Service Code
Agency Referral acknowledged?
Has Client been contacted?
ASCENT COUNSELLING SERVICE REFERRAL FORM
If this is not a Client Self Referral, please fill this section as well as the rest of the form.
Referral Date:
Agency Name and Borough:
Referrer’s Name and Job Title:
Referrer’s Contact Telephone and Email:
Referrer’s Relationship to Client:
Does the client know about this referral? Yes No
Client’s details
Full Name:
Date of Birth:
Telephone:
Email address:
Address including Borough and Postcode:
Safety: is it OK To send post? Yes No
To send emails? Yes No
To send texts? Yes No
To leave voicemails? Yes No
How did you find out about our service?
Pregnancy, Maternity, Children & Other Caring
Is the client pregnant? Yes No
Is the client caring for any children? Yes No If yes, please give their age/s
Does the client have any other
caring responsibilities? Yes No If yes, please say what they are
Marriage/Civil Partnership
Is the client married? Yes No
Is the client in a civil partnership? Yes No
Ethnic background
Asian Bangladeshi Black African Chinese White British
Asian British Black British Latin American White Irish
Asian Indian Black Caribbean Middle Eastern White European
Asian Other ` Black other Mixed Ethnicity White Other
Other – please specify
Religion/Belief
Agnostic Atheist Baha’i Buddhist Christian
Hindu Humanist Jain Jewish Muslim
Rastafarian Sikh Zoroastrian None Other
Prefer not to say
Sexuality
Bisexual Heterosexual Lesbian Other
Prefer not to say
Gender Do you identify as transgender? Yes No
Do you have any disability Issues? If YES, please tick all that apply
No Yes Registered Disability
Blindness/Visual impairment Deafness or Partial Hearing
Learning/Cognitive/Memory Difficulty Mental Health
Mobility Difficulty Other Disability – please state
Employment status – please tick all that apply
Employed Full Time Employed Part Time
Self Employed FT Self Employed PT
Student FT Student PT
Registered Unemployed Receiving a Disability Benefit
No Recourse to Public Funds Unemployed
Presenting issue/s – please tick all that apply
Childhood physical abuse “Honour” based violence Sexual bullying
Childhood sexual abuse Gang-related sexual violence Sexual exploitation
Domestic violence Prostitution Sexual harassment
Forced Marriage Rape Stalking
FGM Sexual assault Trafficking
Other – please state: ______
Involvement with any other agency – please mark all that apply
GP Drugs/alcohol service Counselling Housing
Social care (adult) Social care (child)
Other (please specify): ______
Safeguarding and Risk
Do you know of any Safeguarding issues? Yes No
If “Yes”, please say what they are:
Are you aware of any Risk issues? Yes No
If “Yes”, please say what they are, and indicate the level of risk you identify:
Please briefly detail other issues and concerns, including your agency’s involvement, and details of any information that we need to be aware of:
Agency referrals: Email the completed form as an attachment to citing “Counselling Referral” in the subject header.