To refer to our Outdoor Therapy service please use the referral form at: https://crm.venturetrust.org.uk/ot_referral Thank you. Welcome to the referral page for Venture Trust's Outdoor Therapy and Wellbeing Hub services. It's a big step to ask for help and we would like to recognise that it can be scary too. Once you or the person referring you have completed the form below, an intake counsellor will make contact to arrange an initial discussion. This will give us a chance to explain more about the service and for you to tell us a bit about more about yourself. If we all agree that it's the best thing for you, we will then allocate you to a Therapist who you will begin working with. Client Existing Participant Venture Trust Staff - enter name of existing participant here If referring from outside Venture Trust, please enter "Create New" and fill in details below. First Name Last Name Gender - None -FemaleMaleOther Birth Date Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Street Address City Postal Code Phone Number Email Participant's Medical Information Doctors Name Doctors Phone Number Clinic Name and Address Is the client currently prescribed medication? Yes No If yes, please give details of prescribed medication including what it's for, dosage and frequency here. If you are referring someone else, please complete the details below. If you are referring yourself, please leave this section blank and continue to the next page. Referrer First Name Last Name Phone Number Email Referring Organisation Name of Referring Organisation Start to type your organisation name into the field below. Select the correct option when it appears. If your organisation name does not appear, select Create New to enter it. Organization Name Street Address City Postal Code Local Authority - None -Aberdeen CityAberdeenshireAngusArgyll and ButeClackmannanshireDumfries and GallowayDundee CityEast AyrshireEast DunbartonshireEast LothianEast RenfrewshireEdinburgh, City ofFalkirkFifeGlasgow CityHighlandInverclydeMidlothianMorayNa h-Eileanan SiarNorth AyrshireNorth LanarkshireOrkney IslandsPerth and KinrossRenfrewshireScottish BordersShetland IslandsSouth AyrshireSouth LanarkshireStirlingWest DunbartonshireWest Lothian Reasons for Referral Referral date Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20222023202420252026 This section asks for more details about the participant's mental health and experience of counselling. It should be completed with the participant if possible. Client Information Have you had counselling before? Yes No How long did your previous counselling last? Less than 3 months 3-6 months 6-9 months 9-12 months A year or more Time since previous counselling In the last year 1-2 years ago 2-5 years ago More than 5 years ago Who was your previous counselling with? Although this is primarily a face-to-face service, we may occasionally need to contact you or hold sessions remotely. If this is the case... scoregrid2 YesNo Do you have somewhere where you live that you can have a private conversation? Do you have somewhere where you live that you can have a private conversation? - Yes Do you have somewhere where you live that you can have a private conversation? - No Is there somewhere you could go to have a private conversation without breaking social distancing guidelines? Is there somewhere you could go to have a private conversation without breaking social distancing guidelines? - Yes Is there somewhere you could go to have a private conversation without breaking social distancing guidelines? - No What are the main reasons you think counselling would be helpful for you right now? Do you have a preference for male or female counsellor Male Female No preference Please tick here if you do NOT wish to work with a trainee (trainee counsellors are experienced professionals who are undertaking a further qualification in counselling and are appropriately supported by senior team members) I do not wish to work with a trainee counsellor I would be willing to work with a trainee counsellor Additional Equality Monitoring Questions Ethnic Group - None -White ScottishWhite IrishWhite EnglishWhite WelshWhite BritishWhite Other background (please specify)Asian Scottish or Asian BritishBangladeshiIndianPakistaniChineseOther Asian background (please specify)Black Scottish or Black BritishAfricanCaribbeanOther black background (please specify)Mixed ethnic background (please specify)Other ethnic background (please specify)Not knownPrefer not to say Other white background (please specify) Other Asian background (please specify) Other black background (please specify) Mixed Ethnic background (please specify) Other Ethnic background (please specify) Employment status Unemployed Yes No Individuals in receipt of JSA irrespective of the length of unemployment or Individuals in the ESA Work related Activity Group Long Term Unemployment Yes No (Individuals in receipt of JSA irrespective of the length of unemployment or Individuals in the ESA Work related Activity Group). But for more than: 6 months continuous unemployment (under 25) or 12 months continuous unemployment (over 25) Economically Inactive Yes No Individuals who are not employed or registered unemployed eg Pre-NEET participants Inactive, not in education or training Yes No Individuals who are inactive (see above) who are not in education or training. CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Math question * 10 + 1 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
