20+ years old referral form

Please select your age group

These forms are for self-referrals, or referring someone else.

Please make sure all information is about the person needing support.

Step 1 of 8

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Service user details

Client name

Date of birth

MM slash DD slash YYYY

Landline phone number

Mobile phone number

Address

Street Address Address Line 2 City County Post code

How would you like to be contacted?

Landline phone

Mobile phone

Post

Is it safe to: (tick as necessary)

Leave a message on the telephone numbers you have given?

Identify ourselves to your carers/partner etc on the phone?

Leave you messages via email?

Mark envelopes ‘Private and Confidential’ if we write to you?

First language/languages spoken

Language requirements

Interpreter required

Sign language interpreter required

GP and medical history

GP Name and Surgery

Address

Street Address Address Line 2 City County Post code

GP Phone number

Medical history (optional)

Medication

Allergies

Dietary needs

Disabilities (neurodiverse/ Physical etc)

Referrers information

If you are referring yourself please skip this section

Referrer’s name

Referrer’s organisation

Referrer’s email

Referrer’s phone number

Reason for referral

Services

Please circle/highlight any of the following offered by Alumah which you are you interested in:

Adults

Evolve

Online self-esteem course for anyone

Curve

Provide a safe, supportive, non-judgmental and inclusive environment, enabling individuals the opportunity to gain a positive perspective and response to domestic abuse and intimate partner violence issues

Peer Support

Creative Group – to unwind and relax

Counselling

This is 1:1 support, providing a confidential, secure space to explore and process your thoughts, emotions, experiences and to gain coping techniques. Please see the privacy statement below for more info regarding the confidentiality of counselling.

Phoebes Room

A one-off morning or afternoon workshop about grooming. However, this can lead to a short course of more in-depth about how grooming works. Videos, worksheets, and discussion. This is great for year 6 upwards as this is when the perpetrators will look for victims. Phoebe’s Room is a good insight for parents of children too.

Preferred Location

Online

Brandon

Mildenhall

Newmarket

Bury St Edmunds

Haverhill

Section Break

Counselling

Please skip this section if you're not interested in counselling.

Reasons for coming to counselling

Are you attending counselling with another organisation/professional currently?

Yes

Do you prefer your counsellor to be:

Female

Male

No preference

Where would you prefer to have your counselling?

Bury St Edmunds

Mildenhall

Brandon

Online

Please describe

Other key worker: Name

Other key worker: Phone number

Other key worker: Email

Other key worker: May we contact this worker?

Yes

Third Choice

Emergency Contact

Who should we contact if an emergency happens while you are with us?

Please remember that you may prefer this person to know you are having counselling with us, in case we have to call them in an emergency

Emergency contact name

Emergency contact address

Street Address Address Line 2 City County Post Code

Emergency contact phone number

Emergency contacts relationship to you

Privacy Statement

We are collecting your personal details and GP details to use during our work together. In case of crime or harm to yourself or others, I would need to contact the appropriate authorities. My need for knowing your medication or medical conditions, is to be aware of how these affect you during our work together.

CONFIDENTIAL - EQUALITY & MONITORING

At Alumah we are committed to promoting the best equality practices in our efforts to eliminate discrimination and create environments where all are treated fairly and with respect. We are committed to ensuring that anyone who works at, or uses Alumah, is not treated less favourably than anyone else because of their race, ethnic or national origin, culture, religion, disability, age, gender or sexual orientation.

We will use the information you give us to help monitor the effectiveness of our Equal Opportunities Policy and to help drive our policy and development.

This form is completely confidential. We will never use this information to identify individuals, so please do not add your name.

Consent

To allow Alumah using photos or short videos, which may include the individual in local publications, our social media and website. Please tick the box. N.B most photos will be of projects produced.

Emergency first aid considered necessary N.B. the medical profession takes the view that parental consent to medical treatment cannot be delegated. Medical forms have no legal status, and a doctor has the right to insist on parental consent before treating a child. We have found, however, that medical staff find this type of general consent helpful.

Are you happy for us to keep and store your information on our database? (This is NOT shared with anyone else, unless discussed with you). We need a record of your information to make sure we are working safely and ethically as well as being able to see that you are getting the support you need. We also need to be able to add you to our waiting lists if necessary and without consent to use our database we will be unable to do this.

Are you happy for us to use any feedback you give us?

Confidentiality & Exceptions

Under certain other circumstances it may be necessary for me to breach confidentiality by talking to someone. This may happen if;

You give us your consent for this confidence to be broken.
compelled to break that confidence by a court of law, child protection or the terrorism act 1987.
Harming yourself or others. In such circumstances we would always try and talk to you first.
A referring agency require a report. However, we would devise this together.
We want to reassure you that we will not disclose any information about you to any other agencies or third parties without your knowledge and consent apart from in exceptional circumstances.

Age

7-13

14-17

18-24

25-34

35-44

45-54

55-64

65-74

75 and over

Do you consider yourself to have a disability?

Yes

Prefer not to say

Gender

Female

Male

Transgender

Non-binary

Gender fluid

Prefer not to say

(Please note that although we don't want to put people into boxes, we do need the above information to create the right group dynamics on any given course.)

Religion - Which group do you most identify with? Tick as many as apply.

Buddhist

Christian

Hindu

Jewish

Muslim

Sikh

No religion

Prefer not to say

Any other religion or belief (please specify)

Other religion or belief (please specify)

Sexual orientation