Beacon Counselling Trust – Client Details First Name: Surname: DOB: Gender: MaleFemaleNon-binaryPrefer not to sayOther Contact Number: Consent to Call: YesNo Consent to Text: YesNo Consent to Leave Voice Message: YesNo Email Address: Consent to Email: YesNo Address: Postcode: Has consent been provided by the individual for their information to be shared with BCT and for BCT to make contact with them? YesNo Referral Organisation: Name of Referrer: Please tick the relevant boxes: This individual is at risk of, or experiencing, gambling-related harms. This individual has been impacted by the gambling of someone else. Overview of Presentation: (e.g. gambling type, mental health presentation, risk or safeguarding concerns etc.) Actions: (e.g. interventions, referrals made, signposting etc.) Additional Information: I agree that my submitted data is being collected and stored. This is a specialised service for those who have been bereaved by suicide. If you need to speak to somebody, please contact the office direct on 0151 226 0696 OK
