Outdoor Therapy Referral Form

Counselling for a range of problems including depression, anxiety, trauma, stress, bereavement and life changes.

Please complete our referral form. We will be in contact with you.

If you would like support in completing the referral form, please get in touch at therapy@venturetrust.org.uk

Client name and contact details

We need this information to contact you/the client. If you are referring a child, please enter the parents phone number/email address.

You must give a contact phone number

You must give a contact email address

Bold bordered fields are mandatory

Details

This information will help us understand your/the client’s circumstances.

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You must tell us your date of birth.

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You must tell us your gender.

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You must tell us about your living arrangements.

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You must tell us if you have any dependents.

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You must tell us your employment status.

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You must tell us your ethnicity.

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You must tell us if you are taking any medication.

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You must select a value for this field.

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You must enter a value in this field.

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You must enter a value in this field.

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Why do you think Outdoor Therapy would be helpful right now?

Please tell us a bit about what’s going on at the moment. For example:


What are the current issues or difficulties? (e.g. anxiety, low mood, PTSD symptoms)

Have any other supports been put in place or tried already?

Is the person being referred aware of and in agreement with this referral?

Are there any barriers we should be aware of (e.g. physical or medical challenges that may affect access to Outdoor Therapy)?


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Bold bordered fields are mandatory

By clicking 'send' you're giving permission for the information you have provided us with here to be captured in our electronic clinical record-keeping system, and for us to process this information as outlined in our Venture Trust Outdoor Therapy Service document. Before ticking to indicate your consent it's important to make sure that you have read and understood exactly what you're consenting to by participation in counselling at our service. Please Click here for a full description.

You must tick the consent box.