This referral has NOT been sent yet. You will be redirected to the listing's external referral form. Please complete the referral form there to submit the referral confirm Details Free HIV Counselling by SSHC Who is this referral for? I am signing up myself I am referring someone else Service access criteria Tick to confirm you have checked the service access criteria "To ensure our services reach those who need them most, we have the following access criteria: HIV Positive Status OR Affected by HIV: This service is available to individuals with an HIV positive diagnosis and their friends and family members who are affected by the diagnosis. Age: Clients must be 18 years or older to access individual counselling. (Note: We may have alternative services for those under 18. Please inquire.) Location: Clients should reside in Staffordshire. (Note: We may be able to offer phone or online counselling for those outside this area, depending on circumstances.) Capacity to Consent: Clients must have the capacity to understand and consent to counselling services. No Active Crisis: Clients experiencing an acute mental health crisis or requiring immediate medical attention should seek assistance from emergency services or a crisis support line. We can provide referrals to appropriate crisis resources. " Your Details Email Email is invalid We already have an account with this email. Please log in. Password Reset my password Log in First name Last name Your relationship to the person Organisation name Who are you referring? First name Last name Known as Date of birth Email Don't know / client doesn't have an email address Phone Address Line 1 Address Line 2 Town/City Postcode GP surgery NHS number Gender SelectFemale Male Transgender female Transgender male Non-binary Intersex Not specified Not known Other Additional referral details Do not enter protected health information (PHI) or any other personal data in these fields. What are the reasons for this referral? Sedentary lifestyle High body weight Finances Caring responsibilities Loneliness/isolation Employment Food Poverty Covid/Long Covid Mental health Substance misuse Transport Legal advice Managing a long-term health condition Day-to-day helping hand Victim of abuse Housing problem Bereavement Other: This field is required. Should the service provider be aware of any additional needs? Blind/partially blind Memory problem Hearing loss Housebound Does not speak English Poor mobility Learning and communication needs Physical disability Frail Other: Please share some brief details regarding this referral Confirmation and consent Tick to confirm you have gained consent to share this information with the service provider, your organisation and Joy Tick to confirm the service provider can directly contact the client Would you like to create an account? Make referrals faster next time you use Joy. Registered users can message service providers, submit reviews and track the progress of their referrals online. Password Weak password! Use at least 8 characters Use upper and lowercase characters (a-z) Use 1 or more numbers (0-9) Confirm password Please enter the same value again. required Submit Email: Password: Email
