Therapy - Self Referral Form - Psychology & Counselling- Therapists in Malvern for Adults, Couples & Children

As a service we are reaching capacity for therapy sessions. As of 23.10.24 we are starting a short waitlist. Please only continue if you are happy to be placed on our waitlist. We are currently recruiting more therapists.

I am happy to start the process. I understand the need to respond promptly to future emails or texts should a space become available (self funding clients only).

Due to Insurance Provider rules, we are not allowed to put Insurance Clients on a waitlist. Please revisit this form in a month to see if there is availability.

Are you seeking remote or face to face therapy

I am happy to see a therapist either remote or face to face

I am happy for therapy to be provided remotely

I prefer face to face therapy in Malvern (may be a longer wait)

Who is the client?

I am the client and I am 18 years or older

I am completing this form on behalf of someone under 18 years old (I have parental responsibility)

NHS involvement

I confirm that the client requesting therapy is not presently open to an NHS mental health team i.e. CAMHS, Early Intervention, CMHT, Crisis Service, Perinatal, Older Adult or Eating Disorders. (This does not include being on a waitlist).

If you are 18 years or older, please complete this referral form yourself. [If the client is under 18 years, please tell us your full name and relationship to the client].

Best contact number (please do not put in spaces - mobiles are ideal as we sometimes need to text)

Best email address

Client Information

Please tell us a little bit about the person who is interested in therapy

First Name

Surname

Address and post code

Date of Birth

Age of client

If the client is a child (or young person), what school do they attend? (please state if boarding or day pupil)

Do you give us permission to speak with the school about this referral? (if it is deemed in the child's best interest).

Are you limited to particular session times? (please choose one) Are you limited to particular session times? (please choose one)

How are you wanting to pay for sessions?

Funding sessions myself

Using Health Insurance

Third Party (Company/ Charity)

If you are paying by Health Insurance, which provider is it? (We will need you to complete an Insurance Form with a claim code, before we can book your session)

GP Name

GP Practice

Previous Support

It helps guide our decisions to know what therapy has helped/ not helped in the past

Have you had therapy in the past? (please choose one)

If you have had therapy before, what type was it and how long did it last?

How Can We Help You?

Please give us as much detail as you feel comfortable with. The more details you provide the more we can choose the most suitable therapist for your need.

Are you seeking therapy as an individual or therapy as a couple/ two people attending together?

I would like individual therapy - focussing on my personal struggles

I would like therapy as a couple/ 2 people seeing the therapist together - focussing on our relationship

If you are seeking both individual and couple/ 2 person therapy, please complete a self referral for your individual therapy, and another for couple therapy as we will need to direct you to different Clinicians with different training and skill sets.

If you would like to attend therapy as a couple/ 2 people attending - , please tell us the (1) Full Name and (2) Email of your partner/ family member who will be attending therapy with you. Once your joint appointment is booked, we will email them a Client Registration Form to complete.

Is there a particular type of therapy that you are enquiring about? Is there a particular type of therapy that you are enquiring about?

What is the difficulty that you are seeking support for? ....... Or in what area of your life would you like to see positive changes? (please give as much detail as possible so we can match you to the most helpful type of therapy)

If you are seeking individual therapy, do you require a therapist trained in EMDR?

Sometimes people have nightmares, intrusive thoughts and/ or flashbacks of past events, suggesting underlying trauma. This is useful for us to know as EMDR may be helpful.

Do you have a preferred therapist? (please leave blank if you are open to our guidance)

Sometimes a different therapist to your initial preference, may suit your needs more, or your preferred therapist could be fully booked. When we review your form we may suggest more than one therapist.

What is your preference with regard to timing and frequency of sessions:

I would like the flexibility of booking sessions at different times/ days based on my availability

I would like set sessions at the same time on the same day each week (or fortnight) *

*Our Therapist Simone prefers to see clients at the same time, each week in a set pattern. Other therapists are happy for bookings to be more ad hoc. We will try to match you with a therapist that works in the way you would like.

Caring For Your Safety

Is alcohol a significant problem? (please choose one)

Are recreational drugs being used? (please choose one)

Are there any thoughts of suicide? (please choose one)

Have there been any recent suicide attempts? (please choose one)

If you feel unsafe - either from yourself or someone else - please call 111 and let them know, visit your GP, or 999 if you are in crisis. Other helpful contacts are: 116 123 (Samaritans), 0800 58 58 58 (Calm) or Text “SHOUT” to 85258 or the Domestic Violence Helpline 0808 2000 247 .

Has there been a visit to the G.P. to discuss mental health concerns, in the last month?

Name of next of kin/ trusted adult

Telephone number of next of kin/ trusted adult

This person will only ever be contacted in an emergency, as a last resort should we be extremely concerned about your safety.

Therapy Agreement

What is a Therapy Agreement? A Therapy Agreement is a contract between you and your therapist. It clarifies issues of confidentiality, risk, accountability, attendance, fees, and cancellations.

Professional Accountability - Each therapist in MHPP is fully qualified in their field and adheres to a strict code of professional conduct. Each therapist has evidenced their training and provided references prior to starting with this practice, and have undertaken a rigorous clinical interview to confirm they are working to a high professional standard. All have professional indemnity insurance and completed Enhanced DBS checks. Each therapist discusses cases in supervision and maintains high standards in therapy, notetaking, and professional behaviour.

Personal Data - We are required to collect and store your personal data in case there is a safety risk or a safeguarding concern. Clinical notes will be password protected, accessed only by those within this service, and stored for seven years under legal guidelines. For more information please read our GDPR Policy Document.

Confidentiality & Privacy - Respecting your confidentiality is fundamental to our practice. Confidentiality of your clinical notes and therapy attendance are held within the team. Your Therapist has a duty of care that means that if they have concerns about your safety or that of a vulnerable adult or child, they will disclose limited information of this concern to your next of kin and other services (i.e. GP/ safeguarding team). The concern may also be discussed with other therapists within the team, as part of clinical supervision. Your Therapist will also disclose information if they are legally obliged, or if a serious crime has taken place, especially if others are still at risk (i.e. the perpetrator still has contact with vulnerable adults or children). Your Therapist will aim to discuss all safety concerns with you first, before disclosing information to others, although this is not always possible.

If someone else is paying for your sessions, or has provided card details to our system (i.e. a family member, friend or a third party) and they enquire about your attendance, we may provide limited information pertaining to which sessions have been attended/ missed.

It is agreed that neither party will record any of the sessions with any type of recording device unless written prior agreement of both parties has been given. For full information on confidentiality please read our Privacy Policy.

Cancellation Policy - Please give your therapist at least 24 hours’ notice if you need to cancel or change an appointment by texting their mobile which is on your Confirmation Email. If an appointment is cancelled between 24 – 3 hours, we charge half fee. If cancelled under 3 hours or you do not attend, we will charge the full fee to the stored card connected to your profile. Payments outstanding more than 24 hours after the end of your session may incur a £5 admin fee.

Health Insurance Providers do not pay for missed or cancelled sessions. The outstanding fee will be charged to the stored card, as per your Insurance Agreement.

In the case of any fee disputes, we may provide evidence to your bank of this signed therapy agreement.

Parent/ Carer - By completing this Therapy Agreement we assume you have legal parental responsibility (P.R.) for the above child / young person. It is important you attend one session (or more) alone with the therapist to provide background information and consider how to support the therapy process from a parent/carers perspective.

Notes taken during a parent/ carer session will be stored under the child's profile. The child will be entitled to have access to their notes should they request them, in the future. Please alert your therapist if you want the clinical notes from parent/carer sessions to be stored separately.

V.21.11.23

Consent to Therapy

I am over 18 years old - I have read through the above Therapy Agreement and consent to the terms outlined.

As a parent/ carer of the above child/YP, I have read through the above Therapy Agreement and consent to the terms outlined.

V. 27.08.24

Data Protection

Respecting your confidentiality and privacy is fundamental to our practice.

Your form will be stored securely in our password protected system and governed by strict GDPR rules. If you book in with one of our therapists they will read your referral form before your initial session. We will not share your information outside of our practice, unless you disclose that you (or a vulnerable other) are in imminent danger (from self harm or someone else), we are then legally obliged to report this to your GP/ relevant support service to help keep you safe.

I give consent for my information in this form to be stored and processed as described above

Would you like to receive an email with a link to Dr Abigail's latest YouTube Video, when its released? (They last around 2 mins and are on different psychology topics)

Yes please, I consent to being sent an email with a link to a new video, when it is released

No thank you

How did you hear about our service?

Do you have a question you would like us to answer?

Next Steps

We will review your form, answer questions and make recommendations based on which therapists may be most suitable. We aim to provide you with support as quickly and as simply as possible. Due to high demand, it may take up to 5 days to reply.

We will email our recommendations. (Please check your junk email in case it lands there). You will then be invited to book with your chosen therapist using our online diary, or telephone our office to book.

I consent to receiving an email

I consent to receiving a phone call to discuss my self referral form (between 9 - 5pm)

Thank you for taking the time to complete this form.

Please allow around 7 working days for us to discuss your requirements and write back with recommendations

01684 877 115

Therapy – Self Referral Form

What Service are you seeking?

Self Referral for Therapy/ Coaching