We specialise in working with children, young people and families, but also provide counselling for adults

Name:

Address:

Postcode:

Is it OK to contact you at this address?

Yes No

Contact Telephone Number:

Email Address:

Date of Birth:
Age:

Gender

Choose one... Male Female

Ethnicity:

Is an interpreter required?

Yes No

Who do you live with?

Name, Agency and Contact number of person making the referral:

Date of Referral:

Is this referral made with your full agreement?

Yes No

Are your Parents/Guardian aware of this referral?

Yes No

Are you In Care/Care Leaver?

Yes No

Have you seen a counsellor before?

Yes No

If yes, who and how long ago?

Do you have a Doctor?

Yes No

If ‘Yes’ please give the name and address and telephone number if possible:

Do you have any medical conditions that we need to know about? If yes please specify:

How do you cope when you are stressed or things are going wrong?

Are you taking any prescribed medication that we need to know about?

Yes No

If ‘Yes’ please give details:

Are you receiving support from any other professional?

Yes No

If ‘Yes’ please tick the ones which apply:

Psychologist Nurse
Consultant/Medical Specialist CPN (Community Psychiatric Nurse)
Counsellor Psychiatrist
Dietician Social Worker
Other (please specify)

Who is there to support you in terms of family or friends?

Do you have a learning difficulty or disability?

Yes No

If ‘Yes’ please give details:

Is there a reason why you would have a preference for a male or female counsellor?

Please make us aware of any issue that could affect availability e.g. school, work, training etc

Please tell us briefly what issues or feelings are worrying you at the moment, and that you would like to talk about with the counsellor.

If funding has been agreed please give details of where and to whom the invoice needs to be sent

Name:

Address

We invoice monthly and only charge for sessions completed although sessions cancelled with less than 24 hours’ notice will still be charged at the full rate.