OFFICE USE ONLY
IA Appointment Date, Time and Venue:
Session Appointment Date, Time and Venue:
Confidential Counselling Referral Form
PLEASE COMPLETE AS MANY DETAILS AS POSSIBLE WHILST WITH THE YOUNG PERSON
Young person’s Full name/Gender: / F/MYoung person’s date of birth / DOB AGE
If under 13 years old we need parental consent to hold the young person’s data on our systems (this isn’t consent to participate in the counselling service)
Young Persons Contact Details: / Young Person Mobile
Young Person Home:
Other Contact Number (Full Name/Relationship):
It is essential that the young person is aware of this referral, please tick to confirm this is the case and where possible get young person to sign /
…………………………………. signed
Date of referral:
Worker completing referral:
School/College Employed/Unemployed
Is it OK to: / tick
Identify ourselves to your parents / carers / partner etc on the phone?
Leave you messages via email. Mark envelopes “Private and Confidential” if we write to you?
Who referred you to It’s Your Choice for counselling? ……………………
(if it is a professional please note there name and the name of their organisation)Would you prefer your counsellor to be:
female / male / no preferenceWhere would you prefer to have your counselling?
Please advise young person of appointment times and venues/areas mon-fri 9-4.30 generally,
IA’s are on set days and at set times so may need to miss work/school for appointment..
Location/area (Please refer to previous overview sheet) / day of the week (M-F) / Time (Please refer to previous overview sheet)Are you being supported about your problem by anyone else? / Y/N
please circle your answer
Please give us details of who this is:
worker / name and contact details / may we contactthis worker? *
Doctor /GP
Social Worker
YOT worker/Probation
CPN
CAHMS
Housing support worker
School/college
NEET Advisor
other key worker (please describe)
* If we can make contact with this worker, please sign your name next to their details to give your consent.
Who should we contact if an emergency happens while you are with us?
Please remember that you may prefer this person to know you are having counselling with us, in case we have to call them in an emergency
person’s name/ their relationship to youtheir address
postcode
house phone/mobile phone
Please give us your GP contact details:
GP name and SurgeryGP Address
Postcode
Phone Number