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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 boroughsPLEASE 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 Personal detailsFirst name: Last name:Address:Telephone number(s):Postcode:Email address: Borough:Date of birth: Age:Place of Birth:If you do not speak English, what is your preferred language for counselling? 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 ? Preferred method of contact:Is it ok to write to you? [Post] Yes ? No ? [Email] Yes ? No ?Is it ok to phone to you? Yes ? No ? Is it ok to leave you a message? Yes ? No ? Is it ok to send a text? Yes ? No ? Section 1 - which counselling medium are you referring to? (Please tick all formats you would like to be considered for)Face-to-face ? 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)For remote therapy, you must be able to access a quiet and private room, where you can be alone and not overheard. TELEPHONE ? ZOOM – live video link ? [N.B. To access live video counselling you must have a laptop/tablet/computer/smartphone with reliable internet/Wi-Fi connection]Section 2 - Availability for AppointmentPlease tick when you are available to attend appointments. The more flexible your availability the quicker we can offer you a space.MorningAfternoon Evening(9:00am) (10:00am - 12:00pm)(1:00 - 4:00pm) (5:30 - 7:30pm)Monday ??? ? Tuesday???Wednesday (telephone or live video only) ? ?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: 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 3 – Health servicesAre you currently receiving professional help from any other mental health services?(e.g. Psychiatrist, Psychologist, Psychotherapist, CBT therapist, Counselling) Yes ? No ? Details: If yes, when will the support come to an end? [Date]GP name:GP address:GP Telephone number:Is the GP aware of this referral? Yes ? No ?Are you on any medication?Yes ? No ?If yes, please list 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 have a current job, what is your occupation?If you are not in paid work, are you in receipt of any of the following benefits? Please write amount(s) ?? Employment Support Allowance?? PIP/Disability Living Allowance?? Job Seekers Allowance?? Attendance Allowance ?? Universal Credit?? Carers Allowance ?? Working Tax Credits?? Student Loan?? NASS Accommodation ?? Other benefits (please specify)?? NASS financial support?? No recourse to public funding TFL Freedom PassYes ? No ?? Do not claim benefits ? Not in receipt of benefits ? No access to family income (e.g. due to honour violence, living in abusive relationship) What is your household annual income (including any benefits)? Under ?10,000??20,000 - ?30,000 ??10,000 - ?15,000 ??30,000 - ?40,000 ??15,000 - ?20,000 ? Over ?40,000?Section 5 – HouseholdIf you are pregnant – when is your due date? N/A ?ChildrenDo you have any children?No?Yes?If yes, please state the age of the children: Do you have childcare support for pre-school age children? Yes ? No ? N/A ?If yes, explain how are you supported.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) ? N/A ?If they live with you, do you care for them alone?Yes? No ? N/A ?How many children aged 18 or over do you have? N/A ?Caring duty: Are you responsible for looking after anyone else?Yes ? No ?If yes, please specify the relation:Please describe your living situation ? Live alone ? Living with: ? Children ? Spouse/partner ? parents/guardian ? other relatives/friends ? Dependents (please specify)……………. ? Full/part-time carer (of disabled/elderly etc)? Living in rental accommodation? Living in Council/Housing Association property? Living in a property that you own? Living in shared accommodation (e.g. lodgings)? Living in temporary accommodation (e.g. hostel)? Living in institution/hospital? No fixed address/sofa surfing? If other, please specify……………………………………………Are you currently engaged with any other services? (e.g. IDVA, Social worker, Children services, Faith community etc.) Yes ? No ? If yes, please list it here:Are you currently involved in a court case or any other legal issues? Yes ? No ?When is the case/legal action likely to end?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 ? Please give detailsHow 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? Yes ? No ?If you answered Yes to the above question please tell us more:Are you at risk of harming 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 ? Please give detailsN.B. 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.To support your application, please explain your reasons for seeking counselling.Section 7 – Equality and Diversity 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 group: 18-21 ? 21-30 ? 31-40 ? 41-5 ?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 ? Unsure ? Prefer not to say ?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) ?……………………………Prefer not to say ?Religion or belief?Christianity ? Islam ? Hindu ? Sikhism? Jainism ?Buddhist ? Judaism ? Other ? Prefer not to say ? No religion ? 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 ? (please specify) ………………………………………………………….Blind or visual impairment ?Deaf or hearing impairment ? Learning Difficulty ?Mobility ? Mental Health ? Other disability (please specify) ?…………………………..Prefer not to say ? ................
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