CBT Referral Form

Name
Of the person being referred for sessions.
Preferred Method of Contact
Can we leave a voice message
Have you previously accessed CBT?
Which areas are affecting you? (tick all that apply)
Have you experienced thoughts of self-harm within the last 6 months?
Have you experienced thoughts of suicide within the last 6 months?
Have you ever attempted suicide?
Are you currently at immediate risk of harming yourself or someone else?
Important notice: If immediate risk is identified, we may need to contact emergency or safeguarding services.
Do you have any safeguarding concerns affecting you or someone else?
If yes, please provide details. Important notice: If immediate risk is identified, we may need to contact emergency or safeguarding services.
Are you currently receiving support from any of the following?
Are you currently taking medication for your mental health?
Who is completing this form?
Emergency Contact Name
For Young People Under 18 - Parent/Carer Name
Consent
Preferred Session Type
Privacy Notice & Consent