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Refer Someone Else

Refer someone else to MESMAC's counselling service using our online form. Provide their details and our team will follow up.

Please note the counselling service at MESMAC cannot respond to crisis emotional / mental health situations.

If you feel you are in need of crisis emotional / mental health support - contact your GP or telephone the Samaritans national support line on 116 123 - their telephone line is open 24/7.

Name of staff member

Organisation

Staff contact number

What is the name of the person(s) being referred?

Where do they live?

Please be aware that our counselling services our only available in Bradford, Hull, Leeds and South Yorkshire

What is their postcode?

Could they travel to a different site if the need arose?

If they are a Leeds or Bradford resident, we might ask them to travel to the other city depending on counsellor availability

How will they be travelling to sessions?

Contact number of the person being reffered

Can we leave a message if we can't get through?

Are there any other ways that we can contact them? (eg email)

In case we are unable to contact you by phone

Is the counselling for an individual or a couple?

What are the main issue/s that they would like to resolve during their time with a counsellor?

What days and times are most convenient for counselling to take place?

Is there a strong preference for the counsellor's gender?

Depending on counsellor availability in certain areas, we may not have a choice in this regard. But if we do, we will always take their preference into consideration.

Is the person being referred able to communicate easily in English?

How old are they?

How do they describe their gender?

Do they identify as a trans person?

Yes

How would they describe their sexuality?

What is their ethnic background?

Do they have a disability?

If yes, please select which one is the main disability

We will contact them for more information and if we need to make any adjustments

If you selected other, please specify

Have they ever had or are they currently having any psychiatric treatment or prescribed medication to help with psychological problems?

Have they ever been diagnosed with a mental health condition (eg depression, eating disorder, psychosis, personality discord, etc)?

If you answered yes, please give details

Is there anything else you can tell us about their physical or mental health? (eg any addictions, self-harm, long-term health condition, etc)

Privacy Statement

I have read and understood the MESMAC privacy statement and agree to the use of my data in line with this policy

We are committed to ensuring our counselling service is meeting the need of people who use it? Would the person being referred be happy for MESMAC to contact them for feedback when their counselling has finished?

You will receive an automatic message telling you that we have received your request for counselling.

If our service is not appropriate for you, we will try and let you know within two weeks of receiving your request – with some signposting options if available and relevant.

If our service is appropriate for you, we will attempt to match you with a counsellor within two weeks of receiving your request. You will then negotiate your first session with the counsellor.

Please note that these are guidelines, MESMAC counselling service has a restricted budget which is supplemented by donations to our charity from the public. At times of high demand and unplanned absence the indicative times may be exceeded. At these times we would aim to update the website.

MESMAC privacy statement

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Read our privacy statement