This form is for self-referrals & assisted self-referrals to access Service Six’ services. An assisted self-referral is when you have someone who is helping you to complete this form.
The information provided will be used to enable us to offer the most appropriate services and actions will be kept confidential and securely stored and shared as appropriate within Service Six. Confidentiality is central to our work but it is not absolute - there are legitimate exceptions of some circumstances which require Service Six to share information with others, such as; if a person is at risk of serious harm by others; if a person is at risk of serious harm to them self or to others; or there is a risk of serious crime. A copy of our Confidentiality & Data Protection Policy is available on request or can be found here.
Some information will be used for reporting purposes; in these cases, the data will contain no identifying information that could associate you with receiving a service. Any other information will not be released without your consent unless required by law or a court order as stated above.
We are not able to offer you counselling/therapy if you are seeing another counsellor or psychological therapist, or if you are currently receiving a high level of Mental Health Care. In those cases, we might be able to offer you any other support services which are not counselling.
Prior, during or after you receive a service you can contact Service Six at 01933 277520 or send an email to firstname.lastname@example.org for any questions you might have.
Please complete the form as fully and accurately as you can.
If form does not submit check that you have completed all the required fields