Colchester: 01206 710771
Tendring: 01255 434601
Email: [email protected]
Step 1 of 4
This section should be signed by a family member with parental responsibility or a person over the age of 13
Request for Support | Counselling and Wellbeing North East Essex (Colchester and Tendring) Step 1 of 4 25% Section 1 – Referrer detailsWho are you referring?(Required) Myself Someone else Name of person completing this form(Required) First Last Organisation(if applicable)Relationship to the person being referred(if applicable)Referrers direct contact number(Required)Referrers direct email address(Required) Alternative Contact (If the young person you are referring is below 16 years of age, Please include their parents name and direct contact number)(Required) Name Contact Number Address (Please complete address of individual being referred, including postcode)(Required) Section Two – Person being referredThe main family contact needs to sign consent beside the person being referred, unless they are 13 or over in which case they can sign themselves (section 4.)Name of young person being referred(Required) First Name Surname Family address(Required) Street Address Address Line 2 City County / State / Region Post Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Age(Required)Please enter a number from 0 to 100.Date of Birth(Required) Gender and PronounsContact telephone number(Required)Email address (If the young person being referred is below 16 years of age, please use parents email address)(Required) Do you have any mobility or access limitations?(Required) Yes No If yes, please give details.(Required)Which GP Surgery are you registered with?(Required)Do you take any prescribed medication?(Required) Yes No If yes, please give details.(Required)Are there any other agencies supporting you?(Required) Yes No If yes, please give details.(Required)Are you in Education?(Required) Yes No If yes, please state the name of the school or college.(Required)Where did you hear about YES?(Required)GPCSCAdult Social CareCAMHSNELFTEPUTOther Section 3 – Reason for ReferralPlease indicate the reason(s) for this referral.Please give as much detail as possible.(Required)Is there any other information you want us to know?(Required) Section 4 – Consent to access and share informationThis section should be signed by a family member with parental responsibility or a person over the age of 13 Please read/note carefully and then sign and date the form. If you have concerns, please discuss them with the person working with you. You can note any limit/restrictions in the box if appropriate. Please tick the below to confirm consent(Required) I agree that to the person making or taking the referral that they may check with other services and professionals for information about me/my/our child(ren)that helps make a decision about this referral and that I/we receive the right support. I understand that I have the right to restrict what information may be shared and with whom. I understand that I may withdraw my consent to share information at any time but that might result in a reduction of services being available. Information that I do not want to be shared:(Required)Declaration(Required) I declare that all the information provided is true to the best of my knowledge and full permission has been given from the person being referred.
North East Essex (Colchester and Tendring)
Call us: 01206 710770
