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Contact Us
Family Intervention Counselling Service (FICS)
Home
About Us
What We Do
Outcomes
Current Projects
Our Team
NEWS
GDPR
Training and Volunteering Opportunity
Where else can I get help?
Reporting domestic abuse & Court Orders
Complaints Policy
Modern Slavery Statement
Self Referral Form
Professional's Referral Form
Professional's Victim Referral
Professional's DAPP Referral
Contact Us
Professional's Referral Form
Professional's Victim Referral
Professional's DAPP Referral
PLEASE COMPLETE THE FOLLOWING DETAILS ON BEHALF OF YOUR CLIENT AND EMAIL ANY ADDITIONAL INFORMATION TO
admin@interventionservice.co.uk
Referrer's Details
*
First Name
Last Name
Phone
(###)
###
####
Email
*
Organisation
*
Client's Information
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Is it safe to contact the client by:
*
Choose all that apply.
Phone
Email
Text
Leave voice messages
Phone
*
(###)
###
####
Email
*
Address
*
Gender
*
Male
Female
Transgender Man
Transgender Woman
Non-Binary
Other
Prefer not to say
Prefer to self-describe
Sex
*
Male
Female
Prefer not to say
Unknown
Sexual Orientation
*
Heterosexual
Gay
Lesbian
Bisexual
Other
Prefer not to say
Unknown
Ethnicity
*
White: British, English, Welsh, Northern Irish or Scottish
White: Irish
White: Gypsy or Irish Traveller
White: Other
Mixed/Multiple Ethnic Groups: White & Black Carribean
Mixed/ Multiple Ethnic Groups: White & Black African
Mixed/ Multiple Ethnic Groups: White and Asian
Mixed/ Multiple Ethnic Groups: Other
Asian/ Asian British: Indian
Asian/ Asian British: Pakistani
Asian/ Asian British: Bangladeshi
Asian/ Asian British: Chinese
Asian/ Asian British: Other
Black/ African/ Caribbean/ Black British: African
Black/ African/ Caribbean/ Black British: Caribbean
Black/ African/ Caribbean/ Black British: Other
Other Ethnic Group: Arab
Other
Prefer not to say
Unknown
Nationality
*
UK
Non-UK
Prefer not to say
Unknown
Marital Status
*
Married/Civil Partnership
Co-Habiting
Single
Separated
Divorced/Legally Dissolved Partnership
Widowed
Prefer not to say
Unknown
Religion
*
Unknown
Prefer not to say
Other
No religion
Sikh
Muslim
Jewish
Hindu
Christian
Buddhist
Who does the client live with?
*
Is the client pregnant?
*
If so, when is the due date.
Please give names, ages, DOB of the client's children, and their gender.
*
Does the client require referrals for any additional needs (e.g., services for homelessness, parenting issues, drug misuse, social and community support, finance and benefit).
*
Does the client have any long-standing illnesses, disabilities or infirmities?
*
Has the client's case been referred to MARAC?
*
If yes, please state date.
Is the client experiencing depression, anxiety, self-harm or other mental health issues?
*
Is the client currently using prescribed drugs?
*
If yes, please give details.
Is the client currently using or have ever been dependent on illegal drugs or alcohol?
*
If yes, please give details.
Has the client ever thought or taken suicidal action?
*
If yes, please give details.
Does the client have any convictions/cautions/warnings against them?
*
If yes, please give details.
Has the client ever had problems with being violent or aggressive towards others?
*
If yes, please give details.
Is the client receiving any counselling or mental health services?
*
If yes, please give details.
Is the client required to attend any other services or courses?
*
If yes, please give details.
Has domestic abuse been reported to the police, at the time of this referral?
*
Yes
No
Unknown
Please state what you hope therapy will achieve for the client:
Please give any recommendations for the work:
Please confirm that the information given is correct and that you have obtained the client's permission for this referral.
*
Thank you!