Bereavement Counselling Referral Form
Health Professional

Client Risk Assesment Form

Please note that this risk assessment must be fully completed for all clients referred to our service by health or social care professionals (e.g medical doctors, nursing staff, social workers, occupational therapists, psychologists, counsellors, etc.)

Referrals submitted without this completed form attached will NOT be accepted.

Client Name:

D.O.B:

Address:

Postcode:

Telephone No (Home):

Mobile:

Email:

Preferred method of contact:

Outline reason for referral ( Please include nature and / or date of loss):

Any significant medical conditions or disability:

Is this a cancer related referral?

A Hospice related bereavement?

GP Name:

GP Telephone:

Practice Address:

Referral Source

Name of Individual making referral:

Referral Address:

Referral Postcode:

Referral Telephone Work:

Referral Mobile:

Referral Email:

Record of previous deliberate self harm

Currently threatening suicide and/or self harm

Previous or current incidents of actual or threatened violence

Previous or current threat to use weapons

Threatened or actual aggression towards carers

Misuse of drugs (prescribed or illegal)

Excessive use of alcohol

Evidence of self-neglect (such as poor hygiene)

Evidence of risk through abuse / exploitation from others

Sexually inappropriate behaviour

Other reports of evidence of current risk behaviour

Please use this box for any insufficient information details:

Risks to children: Evidence of current neglect/violence/emotional abuse

Risks to children: Other reports or evidence

Risks to children: Please use this box for any insufficient information details:

Is this client currently engaged in a program of treatment aimed at reducing drug or alcohol use?

Please use this box for any insufficient information details:

Has this client ever been hospitalised for the purpose of psychiatric assessment and/or treatment?

Please use this box for any insufficient information details:

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Bereavement Counselling Referral Form Health Professional

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Bereavement Counselling Referral Form
Health Professional