Name of staff member *
Staff contact number *
What is the name of the person(s) being referred? *
Contact number of person being referred *
Can the counsellor leave a message if they don't get hold of the person being referred? *
Yes No Are there any times that they would prefer not to be contacted?
In case we are unable to contact the person being referred by telephone, are there other methods of contact? e.g. email:
Is the counselling for an individual or a couple? *
Individual Couple What are the main issue/s that they would like to resolve during their time with a counsellor? *
Where do they live? *
Remember, our counselling services are only available in Leeds, Bradford and Wakefield.
Leeds Bradford Wakefield What is their postcode? *
This is so that we know we are providing a full service across the whole of the West & North Yorkshire region covered by Yorkshire MESMAC.
Could they travel to the other two if the need arose?
If they are a Leeds, Bradford or Wakefield resident, we might ask them to travel to one of the other two cities depending on counsellor availability.
Yes No How will they be getting there? *
Public transport Walking Car What days and times are convenient for counselling to take place? *
Is there a strong preference for a male or female counsellor? *
Depending on counsellor availability in certain areas, we may not have a choice in this regard, but if we do we will always take your preference into consideration.
Female counsellor preferred Male counsellor preferred Happy to see either Is the person being referred able to communicate easily in English? *
Yes No How old are they? *
How do they describe their gender? *
Male Female Other If you have selected other, please specify
Do they identify as a Trans person?
Yes No How do they describe their sexuality? *
Gay man Lesbian/ Gay woman Bisexual Heterosexual/ Straight Other If you have selected other, please specify
What is their ethnic background? *
White- White British White- White Irish White- Other White Mixed- White and Black Caribbean Mixed- White and Black African Mixed- White and Asian Mixed- Other Mixed Asian/ Asian British- Indian Asian/ Asian British- Pakistani Asian/ Asian British- Bangladeshi Asian/ Asian British- Other Asian Black/ Black British- Caribbean Black/ Black British- African Black/ Black British- Other Black Chinese Other Ethnic Group Do they have a disability? *
Yes No If yes, please select which one is their main disability. We will contact them for more information and if we need to make any adjustments.
Mobility Learning Disability Sight Impaired Hearing Impaired Other If you have selected other, please specify
Have they ever had or are they currently having any psychiatric treatment or prescribed medication to help with psychological problems?
Yes No Have they been diagnosed with a mental health condition (e.g. depression, eating disorder, psychosis, personality disorder etc.)?
Yes No If you answered yes, please give details
Is there anything else they wish to share about their physical or mental health (e.g. any additions, self-harm, long term health conditions etc.)?
I have read and understood the Yorkshire MESMAC privacy statement and agree to the use of my data in line with this policy *