Counselling Referral Form - Headway Sussex

Date

Patient Surname

Patient First Name

Full Address including Postcode

Date of birth

Telephone number. Landline, Mobile or both

Email address of Patient

Communication/correspondence requirements

Please provide a brief history of your brain injury, or that of the person you support, including any other medical conditions and your current situation

Name & contact details of any other professional or specialist involved (Physio, Speech & Language, OT, Community Rehab Team, Social Worker)

Family Carer Details

We aim to support family Carers Please give details of your family Carer below as consent for us to send further information or make contact: Contact Name: Relationship: Address if different: Email Address: Telephone No:

other you

Name and contact details of person making the referral if not named above

Any other information you may wish to provide:

Please indicate the type of session you would prefer:

Face to face sessions
Online sessions
Telephone sessions

If you have chosen face to face sessions, which location would you prefer?

Newick
Uckfield
Newhaven
East Grinstead/ Forest Row

Consent

We offer counselling in blocks of 6 sessions. Each counselling session cost £40 so a block of 6 sessions costs £240. After your first session we will email you an invoice for 6 sessions. Once this invoice is paid, if you would like further sessions, you can have another block of 6 sessions at a cost of £240. For your information, if you have 12 sessions the total cost will be £480. Please tick the box to confirm that you have read and understood this.
This information is correct to the best of my knowledge
By submitting this form, you confirm that you have obtained consent from the named individual for their personal data to be stored and processed by Headway Sussex in accordance with our Privacy Policy.
This information will be securely stored and used to contact the designated individual. To help Headway Sussex support the named individual more effectively, we may need to share information with and receive information from other parties involved in their support.
All information will be kept strictly confidential and will only be accessible to staff on a need-to-know basis.
I agree to pay £40 per session of Headway Sussex Counselling.