Referral Form

This form is for the use of professionals, other organisations and relevant services who wish to make a referral to MEET in Oxford.

* indicates required fields

Client's details

First Name: * Family Name:* Date of birth: Day/Month/Year Gender: Address Line 1:* Address Line 2: Address Line 3: PostCode:* Telephone Number:* Email Address:*

Referrer's details

Your Name:* Referral agency or professional connection to the client: * Address of referral agency/profession: Agency Address Line 2: Agency Address Line 3: PostCode: Email Address:* Telephone Number:* How long have you known the client? *

Other Information

Please give the name of the client’s GP and address of the surgery: * Name and contact details of other individuals/organisations that have been helping this client: Reason for referral and general circumstances: *

I believe that the client meets the following criteria for this service:

Is resident in Oxfordshire.
Is looking for therapy because their life is seriously affected now by difficult experiences in the past.
Is stable enough to be able to benefit from therapeutic intervention and is able to keep appointments with reasonable regularity.
Has ongoing support available (if needed) for such issues as benefit claims, housing, court cases or immigration status.
Is in control of alcohol or drug use so that there is no significant risk of attendance under their influence.
Is not actively suicidal.
Is unable to pay the usual fees for private therapy or access appropriate trauma therapy through the NHS or insurance.
Could safely meet with a female counsellor in a private room.

Any known risk factors (please include any risk of harm to self or others): *
I confirm that the information above is correct to the best of my knowledge.

I confirm that the client is aware of this referral and that I have permission from them to refer for trauma focused therapy from MEET in Oxford.

MEET in Oxford Making EMDR & Energy Therapies more accessible in Oxford

Referral Form

Client's details

Referrer's details

Other Information

MEET in Oxford

DONATE

Low cost trauma focused therapy with highly experienced Psychotherapists