Referral Form

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

Please select one*

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

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*

Phone Number*

Email Address

Home Address*

Street Address Address Line 2 City County Post Code Country

Please be aware we will use these details to contact you. We will identify ourselves in any communications we have with you.

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:

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

*

Number 2

*

Number 3

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

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

Yes
No

Please give details below:

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

GP surgery postal code/address*

Street Address City/Town/Village Postcode

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

I understand the this is not a crisis service and there will be a waiting list.*

I understand the this is not a crisis service and there will be a waiting list.

I understand this is a short term service and may not be suitable for some young people*

I understand this is a short term service and may not be suitable for some young people.

I understand that the sessions are held during school hours and will require travelling to a base*

I understand that the sessions are held during school hours and will require travelling to a base.

Counselling sessions are confidential, counsellors cannot attend meetings or write reports to add to education plan*

Counselling sessions are confidential, counsellors cannot attend meetings or write reports to add to education plan.

Today's Date*

Name

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

HYA Referral Form

Please complete the form below to refer to our 5-17 counselling service. Please note we do not accept referrals for young people who have a GP based in SO14-SO19 postcodes and we do not accept referrals from Portsmouth City.

Professional section

Parent/Carer section

Child / Young Person section

Referral Consent