Counselling Services for Acquired Brain Injury Survivors and their Carers. Name* First Last Date of Birth* DD slash MM slash YYYY Address Street Address Address Line 2 City County Post Code Mobile NoTel NoIs it acceptable for us to leave a message:with someone answering your phone Yes No with someone answering your phonewith someone answering your phone Yes No Email* (Please note that email is our preferred mode of contact)The client is:* Someone who has had a brain injury? Someone who is actively caring for/or supporting someone with a brain injury? When did the brain injury happen? DD slash MM slash YYYY Where a referral is made by an organisation, please add contact details here of the person making the referral. If this is a self-referral, please use this space to provide details of your GP.Agency/GP Name First Last Name of Person making referral First Last Contact Telephone NoEmail address Agency/GP Address Street Address Address Line 2 City County Post Code We collect the following information about our clients for monitoring only. You are not obliged to complete this section.Gender Male Female Transgender Ethnicity01 - White English/Welsh/Scottish/Northern Irish/British02 - White Irish03 - Gypsy or Irish Traveller04 - Any Other White Background05 - White & Black Caribbean06 - White & Black African07 - White & Asian08 - Any Other Mixed / Multiple Ethnic Background09 - Indian10 - Pakistani11 - Bangladeshi12 - Chinese13 - Any Other Asian Background14 - African15 - Caribbean16 - Any Other Black / African / Caribbean Background17 - Arab18 - Any Other Ethnic Group97 - Prefer not to say98 - Not specified / Not Known99 - OtherPlease give brief details of why you wish to use this serviceAre you receiving any other form of therapy/seeing any other healthcare professional at present? (e.g. psychologist/psychiatrist) Yes No If you are receiving other forms of therapy/seeing any other healthcare professional, please give details belowHave you had any formal diagnosis from a GP, psychiatrist or other mental health professional? Yes No If you have had any formal diagnosis please give details belowPlease give details of all the psychological/psychiatric conditions, you have experiencedHave you had any thoughts of hurting yourself within the past month, which you have wanted to act upon? Yes No If you have had thoughts of hurting yourself please give details belowAre you currently taking any medication, which has been prescribed by a doctor? Yes No If you answered 'Yes' to the previous question please give details about your medication belowWhere did you hear about the service? DisclaimerBy clicking the consent box below you confirm that you have read and understood the information provided within this application form regarding eligibility for the service, charging, data protection and information sharing.* I give consent Personal Data you provide on this form will be held and processed in accordance with our Privacy PolicyName* First Last Upon receipt of this application form, if you meet the Counselling Service’s eligibility criteria, you will be offered an initial assessment appointment before we offer a face to face appointment. Counselling sessions are typically offered in blocks of 6 sessions. At the end of each block of sessions progress will be reviewed to decide if further counselling is needed.Date* DD slash MM slash YYYY Δ