Referral Form

Please complete the form below to refer to our 5-17 counselling service.

Please tell us who you are*

Please select one*

Professional section

Professional's Name*

Professional's phone number*

Professional's email address*

Which Practice, school or organisation do you work with?*

Parent/Carer section

Parent/carer name*

Parent/Carer phone number*

Parent/Carer email address

Do you have Parental Responsibility for the child / young person?*

Child / Young Person section

Child/Young Person First Name*

Child/Young Person Family Name*

Can you give us the child/young person's full date of birth?*

Yes
No

Date of birth

Age*

Please pick one of these options to describe the child/young person:

Please pick one of these options to describe the child/young person:*

Postal Code/Address

Street Address City/Town/Village Postcode

Who can we contact about this referral? Please note we will need to identify who we are.*

First Last

Phone*

Email*

Relation to child/young person:*

Please tell us the name of the GP practice the child/young person goes to*

Please tell us the address or town name of the practice or surgery.

Why are you contacting us? Please tell us how things are at the moment.

Please also provide us with as much information as possible otherwise we will be unable to process you referral

Please choose up to 3 things from this list that are problems at the moment. (Rank them 1-3, with 1 being the most important and 3 being the least important.)*

Number 1

Please could you give us some more details about why you have chosen this problem?*

*

Number 2

Please could you give us some more details about why you have chosen this problem?*

*

Number 3

Please could you give us some more details about why you have chosen this problem?*

Do any of these apply to the child/young person?

You can tick up to 3 items on the list

Are any of these things true for the child/young person?

On the Child Protection Register
Child In Need
Looked After Child

Does the child/young person have support from any organisations or agencies*

Yes
No

Name the organisation:

Do you know the child or young person’s school/college information*?*

Yes
No

School/ College Name:

Address:

Address Line 1 Address Line 2 City County Post Code

Contact at school/ College (teacher/ ELSA):

Are you happy for us to contact the school/ college about this referral?*

Yes
No

Please give details below:

Referral Consent

Does the child/young person know about this referral?*

Does the child/young person consent to this referral?*

If 'no' please give a reason:*

Does the parent/carer person know about this referral?*

Does the parent/carer consent to this referral?*

If 'no' please give a reason:*

Does a healthcare professional know about this referral?*

Does the healthcare professional consent to this referral?*

If 'no' please give a reason:*

Does a teacher or other professional know about this referral?*

Does the teacher or other professional consent to this referral?*

If 'no' please give a reason:*

HYA works in partnership with other agencies, and where appropriate, referrals may be passed onto one of these agencies to meet your needs. Do you consent to information sharing?*

Yes, I consent to information sharing.
No

Today's Date*

Name

This field is for validation purposes and should be left unchanged.