My View - Children’s Therapy Service

(LONDON SERVICE)

Referral Form

Please fill in as much as you can. Remember to include a name, number and/or email for us to contact you.

Today’s date: / Are you referring yourself? Yes No
SHOULD WE CONTACT CLIENT DIRECTLY?
Yes No / IF NO, WHO SHOULD WE CONTACT?
(Please give name and contact details)
CLIENT’S DETAILS [JCDB No……………………………………………………]
First name: / Surname:
Date of birth: / Age (must be under 18):
Is the client being age disputed? (Please give details)
Gender: Male Female Other / Nationality/Ethnicity:
Current address: / Telephone number:
Email address:
Living arrangements: Foster care
Semi-independent / Other (please give details):
Languages spoken:
Interpreter required: Yes No / Interpreter: Male Female
Do you have any concerns about:
Sadness Home life Sleeping Isolation Suicide
Depression Drugs/alcohol Eating Self harm Immigration
Other (please give details):
REFERRER’S DETAILS (if you are not referring yourself)
Name: / Organisation:
Position: / Address:
Email: / Telephone:
Brief reason for your referral:
My View can usually see individual clients on Mondays, Thursdays and Fridays at our offices in Croydon or Wednesdays at our offices in Stratford. Please let us know which day you could attend:
Monday Wednesday Thursday Friday / At My View we can usually supply an interpreter. If you ask us to make initial contact with the client directly, please indicate the client’s level of English:
Read a text? Yes No
Read an email? Yes No
Receive a phone call? Yes No
Immigration and support status
Date of arrival in UK: / Home Office Ref No:
In detention? Yes No / Date of detention:
Just applied for asylum Appeal
Granted asylum Refused asylum
UASC Leave
Other (please give details):
Are you getting support anywhere else, for example school, college, religious groups, other places?
GP Address: / GP Telephone number:

Please check you have completed all fields, and return the form to or by post to: My View, Refugee Council Children’s Section, 13-14 Katharine Street , Croydon CRO 1NX. If you have any questions about My Viewplease call us on 020 7346 1134 or email

British Refugee Council, (commonly called the Refugee Council) is a company limited by guarantee registered in England and Wales, [No 2727514] and a registered charity, [No 1014576]. Registered office: Gredley House, 11 Broadway, Stratford, E15 4BQ, United Kingdom