EACH Counselling and Support – Referral Form

EACH Counselling and Support – Referral Form

Complete the routing questions first. The form will show only the sections relevant to your referral.

1
Routing
These answers determine which form sections you need to complete
Answer all five questions below. The form will automatically show the correct sections based on your answers.
Please select a borough.
Please select an age group.
Please select a primary reason.
Please select a gender.
Please select a referral type.
2
Referral Details
Professional referral information
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3
Client Details MANDATORY
Required for all referrals
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Emergency Contact
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GP Details
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4
DV Form – Ascent / DVAftercare
Domestic Abuse referral – Female only
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e.g. separated, contact due to shared child custody, no contact. Please note we cannot work with women who are still in an abusive relationship.

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5
Young Person Form (11–17 yrs)
Brent borough only – Under 18
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6
Housing Form
Harrow borough only – Male and Female
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Please provide the agency name and how they are involved

Please provide full details of the housing-related issues and timelines where priority is indicated

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7
Peer Support Form – Star Centre
Hounslow borough only – Male and Female
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8
Mental Health Form – Tamil / Mosaic
Mental Health (Hillingdon, Female) / Refugee & Asylum (Hounslow & Hillingdon, Male & Female)
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9
Substance Misuse Form – Jasmine
Ealing borough only – Female only
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10
General Enquiry
No matching service – your enquiry will be recorded
Based on your selections, there is no specific service available for your combination of borough and reason. Please complete this short enquiry form and a member of the team will be in touch.
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11
Consent for Disclosure of Information
Please complete before submitting

I give consent to information about my case being shared between the following professionals, individuals and agencies involved in my treatment.

Professional or Agency Yes No
Relevant keyworker
Internal referral to EACH's other projects
Care manager / social worker
Drugs or alcohol agencies
Probation / IOM / CRC
Homelessness
Housing needs worker / officer
Psychiatrist
Community Mental Health Team / worker
DWP / Jobcentre
HMRC
Social Services
Family Members
Children's Schools
GP
Other Statutory Agencies
Utilities companies
Landlord
Others (please state)
This field is required.
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✅

Referral Submitted Successfully

Thank you. Your referral has been received by EACH Counselling and Support.
A member of the team will be in touch shortly.