top of page

Re-Search North East CIC

Home
About Us
Training
Counselling Support
Re-Search & Innovation
ContactUs
For Professionals
More

Use tab to navigate through the menu items.

For Professionals

This form is for Professional Practitioners - if you wish to refer yourself to our service, please use the Contact Us submission form instead. Please note that we cannot take referrals made my family members or partners.

Name:*

Company name:*

Relationship to client:*

Organisation Address

Country/Region*

Address*

City*

Zip / Postal code*

Contact Number:

Email:*

Client consent to referral.

Consent has been agreed for us to speak to referrer and, where appropriate health care professionals that have been/are involved in the care of client.

Client Full name*

NHS Number (If known)

D.O.B*

Day

Month

Year

Phone

Email

Consent to leave messages

Voicemail

Text

Email

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Consent to Send Written Communication by Post?:

Yes

No

Disability

Ethnicity*

If client is a student, please state the College or Sixth Form:

Is the client a veteran

Yes

No

Service Number

Is the client or their partner pregnant?

Yes

No

Names and D.O.B of any children in client's care

Any safeguarding concerns:*

Yes

No

If yes, please detail any safeguarding concerns:

GP Practice:*

Registered GP:

Current prescribed medication:

Details of previous /current service involvement (e.g. Talking Therapies, secondary services, social services, drug/alcohol service, etc.)

Risk: Has the client... Attempted suicide within the last 4 weeks?

Yes

No

Active suicidal thoughts with plans to act on these?

Yes

No

Active Involvement with Crisis Team?

Yes

No

Is a risk to others?

Yes

No

If yes to any of the above please offer detals of risk to self and to others (including history of self-harm or suicidality and previous convictions):

Reason for Referral

Next of Kin Details

Telephone:

Relationship to client

Client consents to Re-Search North East contacting the, if required.

Address:

Professional Contact? (Where relevant / necessary).

GP

Midwife or Health Visitor

Social Worker

Recovery or Key Worker

Other

If 'Other' please specify:

Name:

Telephone:

Email

Client consents to Re-Search North East contacting them if required.

Connect with Us

Researchnortheast@outlook.com

T: 07802418588 / 07955716277

Accessibility Statement

DONATION QR CODE.jpg

Use the QR code above to support us or pay for your sessions.

Sorbornne Close

Stockton - On - Tees

TS17 6DA

© 2025 by My Site. Powered and secured by Wix

bottom of page