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. Please complete the form below to refer to our 5-17 counselling service.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 professionalDo 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 Professional 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?*YesNoChild / Young Person sectionChild/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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 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 BelowFemaleMaleTransgenderUnsureOtherPlease 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 knowSelect Below*Number 2Select BelowAnxietyLow moodDepressionAngerFamily and relationship issuesLoss, bereavementSelf-destructive behaviourLow self-esteemEating / body imageSelf harmSuicidal feelingsDiagnosed mental health disorderI don't knowSelect Below*Number 3Select BelowAnxietyLow moodDepressionAngerFamily and relationship issuesLoss, bereavementSelf-destructive behaviourLow self-esteemEating / body imageSelf harmSuicidal feelingsDiagnosed mental health disorderI don't knowDoes 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 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* DD slash MM slash YYYY NameThis field is for validation purposes and should be left unchanged.
