Please complete the form below to refer to our 5-17 counselling service.Child / Young Person sectionChild/Young Person First Name*Child/Young Person Family Name*Can you give us the child/young person's full date of birth?*YesNoDate of birth Date Format: DD slash MM slash YYYY Age*Please pick one of these options to describe the child/young person:*Select BelowBlankWhite BritishIrishTraveller of Irish heritageAny other white backgroundBangladeshiIndianPakistaniAny other Asian backgroundBlack CaribbeanBlack AfricanBlack otherChineseMixed white / black AfricanMixed white / black CaribbeanMixed white / AsianAny other mixed backgroundAny other ethnic backgroundUnknownPlease pick one of these options to describe the child/young person:Select BelowFemaleMaleTransgenderUnsureOtherPostal Code/Address Street Address City/Town/Village Postcode 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 1Select BelowAnxietyLow moodDepressionAngerFamily and relationship issuesLoss, bereavementSelf-destructive behaviourLow self-esteemEating / body imageSelf harmSuicidal feelingsDiagnosed mental health disorderI don't know*Number 2Select BelowAnxietyLow moodDepressionAngerFamily and relationship issuesLoss, bereavementSelf-destructive behaviourLow self-esteemEating / body imageSelf harmSuicidal feelingsDiagnosed mental health disorderI don't know*Number 3Select BelowAnxietyLow moodDepressionAngerFamily and relationship issuesLoss, bereavementSelf-destructive behaviourLow self-esteemEating / body imageSelf harmSuicidal feelingsDiagnosed mental health disorderI don't knowDo any of these apply to the child/young person?You can tick up to 3 items on the list Educational Health Plan Early Help Hub Physical disability Long term illness Sensory impairment Autism spectrum disorder Dyslexia/Dyspraxia ADHD Homelessness Pregnant / young parent Poverty Drugs or alcohol Exploitation, abuse Neglect Care leaver Experiencing discrimination Experiencing bullying Issues with education Armed forces household 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*YesNoName the organisation:Do you know the child or young person’s school/college information*?*YesNoSchool/ 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?*YesNoPlease 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 Please tell us who you are*Please select one*I am a child / young person referring myselfI am a parent / carer referring a child or young personI am a healthcare professionalI am a teacher or other professionalProfessional sectionProfessional's Name*Professional's phone number*Professional's email address* Which Practice, school or organisation do you work with?*Parent/Carer sectionParent/carer name*Parent/Carer phone number*Parent/Carer email address Do you have Parental Responsibility for the child / young person?*YesNoReferral ConsentDoes the child/young person know about this referral?*Select BelowYesNoDoes the child/young person consent to this referral?*Select BelowYesNoIf 'no' please give a reason:*Does the parent/carer person know about this referral?*Select BelowYesNoDoes the parent/carer consent to this referral?*Select BelowYesNoIf 'no' please give a reason:*Does a healthcare professional know about this referral?*Select BelowYesNoDoes the healthcare professional consent to this referral?*Select BelowYesNoIf 'no' please give a reason:*Does a teacher or other professional know about this referral?*Select BelowYesNoDoes the teacher or other professional consent to this referral?*Select BelowYesNoIf '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* Date Format: DD slash MM slash YYYY PhoneThis field is for validation purposes and should be left unchanged. 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