Critical Incident Support

Overview

Introduction

If you are concerned that you or someone you know is at immediate risk of harm contact 999

Wellbeing Solutions offers Critical Incident Support to help teams and individuals manage the emotional and psychological impact of a challenging event. This referral form enables HR professionals to arrange counselling services tailored to individual employee needs.

Role of a Critical Incident Responder

Our Critical Incident Responders provide specialist debriefing and initial stabilisation to support those affected at all levels within your organisation. This process helps individuals process their emotions and reactions in the immediate aftermath of a critical event.

How it works

Consult with relevant colleagues (especially onsite managers and those closely affected individuals) before submitting a request.
Submit this form with all the required details.
Clinical Team Review: Our clinical team will assess whether Critical Incident support is the most appropriate intervention.
Confirmation & Booking: If approved, our team will arrange for a responder on the requested date and confirm the booking.
Follow-up Call (if needed): We may contact you to discuss the incident in more detail to clarify any information.

For urgent queries, contact Wellbeing Solutions at 020 7708 5000 or email customerservices@wsm-wellbeing.co.uk.

Select Critical Incident Response Type

Please select the type of response you wish to request and the delivery method. This ensures the service provided aligns with the employee’s needs and your organisational requirements.

Select Response Type

Rapid Response – Half Day (£980.00): 3 hours of Critical Incident Support within 2 working days of the submission of this form Rapid Response – Full Day (£1,750.00): 6 hours of Critical Incident Support within 2 working days of the submission of this form Standard Response – Half Day (£750.00): 3 hours of Critical Incident Support after 2 working days of the submission of this form Standard Response – Full Day (£1,350.00): 6 hours of Critical Incident Support after 2 working days of the submission of this form

Select Method

Online Delivery Onsite Delivery

Important note

Important Note: If you are choosing Onsite Delivery, please ensure that there is a suitable, private & comfortable room available which can facilitate a group session and/or individual 1:1 sessions.

Your Organisation and Referrer Information

Please provide your organisation’s details and the contact information of the person submitting this referral. This ensures we can process the request efficiently and reach out if further clarification is needed.

Organisation name

Name

Job title

Telephone number

Mobile number (required if not office based)

Email address

Date of referral

Day to Day contact

This is the person we will contact regarding the setup of the CI on the day and prior.

Day to day same same

The person making this referral is the day to day contact

Day to day contact name

Job title

Telephone number (mobile is preferred)

Email address

Critical Incident Details

Please provide the following information about the incident which occurred. This will allow us to coordinate the response effectively. All details will be handled in strict confidence, in accordance with GDPR and Wellbeing Solutions' data protection policies.

Date of incident

Full summary of incident

Number of employees affected

Number of employees to attend

Please specify if you would like the response to be a group session, 1:1 session or a mixed approach

Date of support required

Location where support is required

Risk and Safeguarding Details

Please complete this section to highlight any known risks or safeguarding concerns. This information helps us deliver safe and appropriate support for the employee. If no risks are known, mark "No" in the relevant sections.

Are any of the individuals attending known to be at risk of harm to themselves or others?

Yes No

Please describe the known risks

Have any of the individuals caused harm to themselves or others within the last three months?

Yes No

Please provide details

Are there any other safeguarding concerns we need to be aware of?

Yes No

Please outline these concerns

999

If you believe there is an immediate risk to the employee or others, please contact emergency services by dialling 999.

Billing and Invoice Details

Please complete the following details for invoicing. Invoices will be issued separately from your organisation’s EAP subscription for sessions delivered.

Invoice recipient name

Job title

Telephone number (mobile preferred)

Email address

Postal address (including postcode)

Does your organisation require a purchase order number or finance reference?

Yes No

Please provide details of the purchase order number or finance reference

Billing note

Note: Invoices will reflect charges for sessions delivered and may be issued separately. For billing or invoicing queries, please contact customerservices@wsm-wellbeing.co.uk.

Terms and Conditions for Critical Incident Services

Commitment upon submission:
By submitting this referral form, the authorising manager confirms approval for Wellbeing Solutions to arrange additional counselling sessions as specified. This referral constitutes a binding contractual agreement.
Service confirmation and delivery:
Wellbeing Solutions will contact the employee directly to arrange counselling sessions based on the selections made in this form. Sessions will be delivered by qualified clinicians in line with Wellbeing Solutions’ clinical governance standards and the BACP Code of Ethics.
Confidentiality:
The employee’s identity, previously confidential under the EAP self-referral process, has been voluntarily disclosed for the purposes of this referral. All personal and session details will remain confidential and managed in line with GDPR and the Data Protection Act 2018.
Cancellation policy:
- Three or more working days’ notice: 50% of the agreed fee will be charged.
- Anything less than three working days: 100% of the agreed fee will be charged.
- Rescheduling requests made with less than three working days’ notice will incur a £50 administrative fee in addition to the standard cancellation fees.
Payment terms:
- You will be invoiced for all billable sessions outlined above upon receipt of this order.
- Invoices are due within 30 days of issuance.
- Late payments may incur interest at 4% above the Bank of England base rate, calculated daily from the due date.
Safeguarding:
Any risk or safeguarding concerns disclosed within this form will be managed in line with Wellbeing Solutions’ safeguarding policy. For immediate concerns, please contact emergency services by dialling 999.
Liability:
Wellbeing Solutions shall not be liable for indirect or consequential loss arising from the delivery of services, including delays caused by circumstances beyond reasonable control.
Clinical governance:
Counselling sessions will be provided by clinicians adhering to Wellbeing Solutions' clinical governance standards and the BACP Code of Ethics.
Amendments to This Agreement:
Any changes to this referral must be requested in writing and confirmed by Wellbeing Solutions prior to implementation.

Acknowledgment and agreement:
By checking the box below, I confirm that I have read, understood, and agree to the terms and conditions outlined above.

Terms

I agree to the terms and conditions.

Authorisation and Submission

By completing the fields below and clicking "Submit," you confirm your request for additional counselling sessions as outlined in this referral form. Upon submission:

An Adobe-signed PDF will be generated and emailed to the contact email address provided.
A copy will also be sent to Wellbeing Solutions to initiate the order process.
A member of our team will contact you shortly to finalise details and confirm the booking.

Full name

Job title

Date

Signature

Progress bar

Introduction

Role of a Critical Incident Responder

How it works

Select Critical Incident Response Type

Your Organisation and Referrer Information

Day to Day contact

Critical Incident Details

Risk and Safeguarding Details

Billing and Invoice Details

Terms and Conditions for Critical Incident Services

Authorisation and Submission