Case No: - The Maya Centre — Counselling for Women



4105275627380Case No:00Case No: Referral and Application Form To be eligible for counselling at the Maya Centre a person must be:?A woman over 18 years of age ?In receipt of a means-tested state benefit (does not include child benefit)?Have a connection to the London Borough of Islington**We also have some spaces for women from neighbouring boroughs.Return this referral form by email to?admin@.uk?An online version of this form can be found at SELF-REFERRALS ONLYPLEASE COMPLETE ALL PARTS OF THIS FORM IN FULLSection 1 – Applicant Contact Details At the Maya Centre we regard inquiries and counselling discussions as private and confidential. Any information provided will be treated in confidence. No information of any kind is given to anyone outside of the Centre unless specifically requested in writing, although in rare circumstances we reserve the right to widen confidentiality if there appears to be a serious risk of harm.The data collected on this form and any other subsequent paperwork containing information about you is held in accordance with the Data Protection Act 2018, which states that your information must be: used fairly and lawfully, used for limited, specifically stated purposes, kept for no longer than is absolutely necessary, must also be accurate, and kept in a safe and secure place. You have the right to see your records at any time.? New client ? Previous Maya Centre client ( referral to group therapy/workshops only)Personal detailsFirst name: Last name:Address:Telephone number(s):Postcode:Email address:Borough:Date of birth:Place of Birth:Language preferred:Are one or more of your parents or grandparents Irish? Yes ? No ?If Irish, were you or your parents a resident of an Irish institution? Yes ? No ? Live video counselling If your circumstances stop you from accessing counselling due to mental or physical health issues, this could be the service for you.To access live video counselling you must have a phone/laptop/computer that is connected to the internet/wifi. Additionally, the room you use to take part in the counselling session must be private and safe where you are not overhead. ?Yes, I have all the above ?No, I do not have the abovePreferred method of contact:Is it ok to write to you/your client? Yes ? No ? Don’t Know ?Is it ok to phone to you Is /your client? Yes ?No ? Don’t know ?Is it ok to leave you/your client a message? Yes ?No ? Don’t Know ?Is it ok to send a text? Yes ?No ? Don’t Know ?How did you hear of the Maya CentreClinician?College/University?Self?Counselling Organisation?Voluntary/Community Sector?GP?Media/Books?CMHT?Social Services?Maya Centre Website?Other source (please specify)?Hospital ?Do you have any connections with any Maya Centre staff Yes ? No ? If yes, what is the connection?Section 2 - Availability for AppointmentPlease note counselling appointments are held on the hour at each hour, and your greater availability leads to less wait for appointment. Please tick when you are available to attend appointments: MorningAfternoon Evening(9:00am) (10:00am - 12:00pm)(1:00 - 4:00pm) (5:30 - 7:30pm)Monday ?? ? Tuesday???Thursday?? Friday???Do you have any specific access needs?Yes ? No ? e.g. hearing loop, wheelchair access, visual impairment, reading difficulty If you answered Yes above, please tell us more: Please note that the Maya Centre is upstairs on the second floor. You need to tell us if you cannot manage stairs.?Yes, can manage stairs ?No, cannot manage stairs. (Appointments will be held at an accessible venue nearby)Section 3 - MedicalAre you currently receiving professional help from any other services?(e.g. Psychiatrist, Psychologist, Faith community, Social worker, etc.) Yes ? No ? Details: GP name:GP address:GP Telephone number:Is the GP aware of this referral? Yes ? No ?Are you on any medication?Yes ?No ?Details of medication: Section 4 – Employment and incomeWhat is your current work situation?In paid work:Full time ? Part time ? Self-employed ?Not in paid work ? In receipt of state pension?Student ?If you are not in paid work, are you in receipt of any of the following benefits? Please write amount(s) ?Incapacity Benefit ?_______ Disability Living Allowance?_______Jobseekers Allowance ?_______ Income Support?_______Working Tax Credits ?_______ Housing Benefit?_______Child Benefit ?_______ Carers Allowance ?_______Attendance Allowance ?_______ Employment & Support Allowance?_______NASS Accommodation ?_______ NASS financial support?_______Student Loan?_______ In receipt of other benefits (please specify) …………………………………………… ?______No recourse to public funding ? Do not claim benefits ?No access to family income (e.g. due to honour violence, living in abusive relationship) ?Not in receipt of benefits? Freedom PassYes ? No ?If you have a current job, what is your occupation?What is your household annual income (including any benefits)?Under ?10,000??10,000 - ?15,000??15,000 - ?20,000 ? ?20,000 - ?30,000??30,000 - ?40,000?Over ?40,000?ChildrenDo you have any children?Yes?No?If yes, please state the age of the children: If you have any children under the age of 18, do they live with you?Yes ?No – they live elsewhere in the UK?No – they live outside the UK ?No – I don’t know where they are?Other (please specify)If they live with you, do you care for them alone?Yes?No?How many children aged 18 or over do you have?Are you responsible for looking after anyone else?Yes ? No ?Please describe your living situation (e.g. living alone, with a partner, with children, with parents, in room, flat, etc.) Are you currently engaged with any other services? Yes ? No ?If yes, please list it here:Section 5 – Current DifficultyWhat has led to this application to the Maya Centre for counselling at this time? Anger / aggression ? Childhood sexual abuse ? Coping with change ? Cultural Issues ? Depression ? Domestic Violence ?Drug / alcohol misuse ? Eating disorder ? Family problems ? FGM/cutting of genitals ? Financial problems ? Loneliness / isolation ? Loss through death ?Low Self-esteem ?Panic attacks ? Physical health problems ? Psychotic episodes ? Rape ? Relationship problems ?Self Harm ? Separated from children ?Sexual abuse ?Sexuality issues ? Stress / Anxiety ? Suicidal attempts (in past) ? Suicidal attempts (recent) ? Suicidal thoughts (past) ? Suicidal thoughts (recent) ?Violence/abuse from your children ? Other ? Details: How long have you been experiencing the difficulties or concerns mentioned in the above question? A few days ? A few weeks ? A few months ? A few years ?Are you at risk of being harmed or a risk to others? Yes ? No ?If you answered Yes to the above question please tell us more:What helps you cope or manage your situation? e.g.Alcohol?Boyfriend / girlfriend / partner ?Drugs ? Exercising ?Family?Friends ? Hobbies?Self harm ?Sleeping a lot ? Socialising a lot ?Staying in ?Other ? Details:If you are misusing drugs and alcohol you might have to be engaged with specialist services or manage the condition in order to be able to benefit from counselling sessions.Is there anything further/information we should have before we consider you for counselling? Section 7 – Monitoring FormThis Information is gathered for statistical purposes and is removed from your referral - Any information shared with outside organisation, i.e. funders is always anonymised. Age: 18-21 ? 21-30 ? 31-40 ? 41-50 ?51-60 ? 61-64 ? 65 or over ?Gender Identity:Female?Transgender?Prefer not to say?Other gender identity (please specify)Sexual identity:Bisexual?Heterosexual?Lesbian?Prefer not to say?Unsure?Other sexual identity (please specify)Ethnicity:White:British? Irish ?Greek Cypriot?Turkish?Kurdish ?Albanian?Kosovan?Other white background (please specify)Asian or Asian British:Indian?Pakistani?Bangladeshi?Mixed:White & Black African ?White & Black Caribbean ?White & Asian ?Other mixed background (please specify)Black or Black British:African?Caribbean ? Other black background (please specify)Other Ethnic Group:Afghani?Arabic?Chinese?Iraqi?Latin American? Middle Eastern?Kosovan?Other Ethnic background (please specify)…………………………………………………….Are you a refugee or asylum seeker?Yes?No?Disability:Do you consider yourself to have a disability? Yes?No?Long-term condition – Diabetes, lupus, asthma, rheumatism, arthritis, cancer, MS etc ?Blind or visual impairment?Deaf or hearing impairment?Learning Difficulty?Mental Health?Mobility?Prefer not to say?Other disability (please specify) ................
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