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PROFESSIONAL REFERRAL

Referrer's Details

Client Information

Birthday
Day
Month
Year
Multi-line address
What Hub services are of interest?
Are you currently receiving support form a psychiatrist, psychologist or counsellor ?
Yes
No
Have had previous support
Any current mental health related medication?
Yes
No
Unsure
Private or social housing
What is their availability (tick all that apply) PLEASE ONLY INDICATE TIMES THAT THE CLIENT IS AVAILABLE. We allocate clients based on their availability and if they are unable to attend when they have indicated this will increase waiting times.

Counselling Client Contributions

MHWH is charitable incorporated company run by volunteers and counsellors . We are funded for 12 months by Platform housing, The National Lottery, Malvern Town Councill ,MHDC and the CO OP with rooms provided by Malvern Town Football club . The client contribution is not only an investment in yourself and your future , but also allows us to continue to support the community . We understand that times are hard and so we have kept costs to the very minimum that we can . But to comply with our funders and to be able to deliver the service we ask for your support and investment into yourself and your community . A £10/£20 or £30 contribution required to be paid in advance to your counsellor for the first session/assessment dependent on income .

Client Contributions
Application for a concession
Would like to be contacted to apply for concessions to reduce contributions after the first session (a form to gather further information will be sent out to apply for concessions )
Client Commitment
I confirm that the client is able to attend sessions at the same time weekly and understands that we allocate our sessions based on their indicated availability .
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