Inter Agency Referral

Relate Bradford Inter-agency Referral Form
Please complete this form by giving as much detail as possible.
Your details:

Agency (required)

Name (required)

Role (required)

Date (required)

Phone (required)

Your Email (required)

Postal address (required)

Postcode (required)

Additional Information
Required for each family member

Ethnic Origin (required)

Religion (required)

Sexual Orientation (required)

Disability (required)
YesNo

Referral Source (required)

Reason for Referral (required)

Details of referral
Type of counselling required: (required)
Young personsFamilyRelationshipIndividualCaring and SharingIndividual and Couple Therapy for DepressionSex TherapyPsychosexual support

Have the clients been referred to Relate Bradford before? (required)
YesNo
If yes please give details.

If you are referring from the local authority, is involvement:
VoluntaryMandatory

What are the clients' views of the referral?

Have the clients consented to the sharing of information between our organisations? (required)
YesNo

Are there any court proceedings current or pending? (required)
YesNo
If yes please give details (please give details of any injunctions that are in place)

Details of the client(s) you are referring – adult clients
Please include the details for parents/carers in this section as they will be asked to attend an assessment if the referral is for young persons counselling and the young person is under 16.

Adult client 1
Name

Date of birth

Gender
—Please choose an option—MaleFemaleOtherPrefer not to say
Address

Postcode

Medical centre

Home phone number:

Work phone number:

Mobile phone number:

Email:

Partner if attending
Name

Date of birth

Gender
—Please choose an option—MaleFemaleOtherPrefer not to say
Address

Postcode

Medical centre

Home phone number:

Work phone number:

Mobile phone number:

Email:

Does the client(s) have any special needs or disabilities?
YesNo
Does the client(s) have any language needs?
YesNo
If yes please give details.

Contact restrictions (please tick all that apply)
Okay to say Relate callingOkay to emailOkay to write to addressPartner is not aware of contactUnder 16 – parents aware of contact

Preferred Time(s) for an appointment (please tick all that apply)
MondayTuesdayWednesdayThursdayFridaySaturdaySundayMorningAfternoonEvening

Details of the client’s children

Are any of the children on the child protection register?
YesNo
If yes please give details.

Is there a CAF in place?
YesNo
If yes please give details.

Child 1
Name

Date of birth

Address

Postcode

Medical centre

Gender
—Please choose an option—MaleFemaleOtherPrefer not to say
Parent/Guardian

School

Child 2
Name

Date of birth

Address

Postcode

Medical centre

Gender
—Please choose an option—MaleFemaleOtherPrefer not to say
Parent/Guardian

School

Child 3
Name

Date of birth

Address

Postcode

Medical centre

Gender
—Please choose an option—MaleFemaleOtherPrefer not to say
Parent/Guardian

School

Other agencies

Are any other agencies involved with the client(s)?
YesNo
If yes, please provide as much detail as possible about who is involved and their involvement.

Payment
Relate Bradford is a not for profit charity and we ask for client contributions towards the cost of counselling sessions.
We have a limited number of fully funded relationship and psychosexual therapy counselling
sessions available.
We have a limited number of fully funded Young People and Family counselling sessions
available.
We have a limited number of fully funded Caring and Sharing sessions available.
People attending Relate services are asked to make a payment contribution towards the cost of their counselling or therapy, if fully funded sessions are not available.

If you live out of the Bradford postcode area, the price for all services will be £50 for the registration and assessment appointment, then £90 for ongoing sessions.

Reasons for referral
What has prompted you to make this referral?

What does the person hope to achieve with this referral?

What do you hope to achieve with this referral?

Family tree
Issues affecting the family (please provide as much detail as possible)
Parental drug/alcohol abuse.

Child drug/alcohol abuse.

Mental health issues adult/child.

Physical health issues adult/child.

Domestic violence.

Physical abuse.

Sexual abuse.

Education issues.

Child behavioural issues.

Parenting skills.

Other. (please specify)

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