Refer Someone Else

Use this form to arrange counselling for somebody else.

Name of staff member *

Organisation *

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? * 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? * 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 Bradford.

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. Remember, only people living in LS and BD postcodes are eligible.

Could they travel to the other if the need arose?

If they are a Leeds or Bradford resident, we might ask them to travel to the other city depending on counsellor availability.

How will they be getting there? * 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.

Is the person being referred able to communicate easily in English? * How old are they? *

How do they describe their gender? * If you have selected other, please specify

Do they identify as a Trans person? How do they describe their sexuality? * If you have selected other, please specify

What is their ethnic background? * Do they have a disability? * 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. 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? Have they been diagnosed with a mental health condition (e.g. depression, eating disorder, psychosis, personality disorder etc.)? 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 *

Yes

We are committed to ensuring our counselling service is meeting the needs of the people who use it. Would you be happy for MESMAC to contact you when your counselling has finished (or when you end your counselling) for your feedback?

Yes No

You will receive an automatic message telling you that we have received your request for counselling.

If our service is not appropriate for you, we will try and let you know within two weeks of receiving your request – with some signposting options if available and relevant.

If our service is appropriate for you, we will attempt to match you with a counsellor within two weeks of receiving your request. You will then negotiate your first session with the counsellor.

Please note that these are guidelines, Yorkshire MESMAC counselling service has a restricted budget which is supplemented by donations to our charity from the public. At times of high demand and unplanned absence the indicative times may be exceeded. At these times we would aim to update the website.

Yorkshire MESMAC privacy statement

Click here to read

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Refer Someone Else

Yorkshire MESMAC privacy statement