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Counselling Referral

The information that you provide on this form will be used by Base 51 in a number of ways. Please read each section of this form carefully so that you understand what information and data we will store about you, and how this will be used. If you are not sure what things mean, please talk to a member of staff before completing this form who will explain it for you.


Base 51 is fully committed to protecting your data and complies with the General Data Protection Regulations (GDPR). This is a piece of legislation in place across the UK and Europe designed to make sure that your rights as an individual are protected, if you would like to know more about this please ask a member of staff.


We store your data on secure systems and only authorised workers have access to look at this information.

As a charity, Base 51 has to create reports about how well we are meeting our aims and objectives and this is called “monitoring”. Any information we gather from this form to use for our monitoring reports is always anonymous. This means that you, as an individual, cannot be identified from these reports.


The Base 51 Counselling Service is confidential. This means that we will not give out information about you. It is important for you to understand that sometimes we might have to break this confidentiality. If we think that there is any risk of harm to you, or to anyone else, we might have to tell other agencies (like your parent/carer, the Police, Social Care or the Child and Adolescent Mental Health Service) to ensure the safety of you or other people. We have a legal obligation to do this (this means that the law says that there are certain things we have to do to keep people safe), but wherever possible we will talk to you about this first so that you know what information we are sharing.

You have the right to ask us to stop using your data, and in some cases to have it deleted completely. If you would like to do this, please talk to a member of staff who will give you more information.

This form uses some words that you might not have heard before. Here is what we mean:

· Data – this is the piece of information you are providing. For example, your date of birth is one piece of data, and your address is another piece of data.

· Comply (or complies) – this means to follow all of the rules or laws that are in place

· Legislation – this is another name for a group of laws about a particular subject

· Monitoring – the reports and information that Base 51 create to show that the organisation is meeting its aims and objectives

· Anonymous – not identified by name or any other information that would make it clear who you are

· Processing – to use the data in any way, for example to add it to a system or to use it as part of a report

· Mandatory – this means that we must to have the information in order to carry out our work, or to provide you support

· Optional – this means you can choose whether or not you share this information

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