Paid-for Counselling Service Form

Paid-For Counselling service | Request for Support

North East Essex (Colchester and Tendring)

Step 1 of 4

25%

Section 1 – Referrer details

Who are you referring?(Required)

Myself

Someone else

Name of person completing this form(Required)

First Last

Organisation (please state clearly the type of organisation you represent, such as school, GP surgery, CAMHS, social care etc.)

(if applicable)

Gender and preferred pronouns

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 referred

The 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 Country

Age(Required)

Please enter a number from 0 to 100.

Date of Birth(Required)

Gender and Pronouns

Contact 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

If yes, please give details.(Required)

Which GP Surgery are you registered with?(Required)

Do you take any prescribed medication?(Required)

Yes

If yes, please give details.(Required)

Are there any other agencies supporting you?(Required)

Yes

If yes, please give details.(Required)

Are you in Education?(Required)

Yes

If yes, please state the name of the school or college.(Required)

Where did you hear about YES?(Required)

Section 3 – Reason for Referral

Please indicate the reason(s) for this referral.

Please give as much detail as possible.(Required)

Presenting Issues (please tick any of the following which apply)

Anxiety

Behaviour

Bereavement

Bullying

Depression

Eating disorder

Family conflict

Friendship issues

Gender identity or sexual orientation

Neurodiversity

School issues including school avoidance

Self-harm

Suicidal thoughts

Trauma

Please include any other information which might be helpful.

Is there any other information you want us to know?(Required)

Section 4 – Consent to access and share information

This 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.

Paid-For Counselling service | Request for Support

North East Essex (Colchester and Tendring)

Step 1 of 4

25%

Section 1 – Referrer details

Who are you referring?(Required)

Myself

Someone else

Name of person completing this form(Required)

First Last

Organisation (please state clearly the type of organisation you represent, such as school, GP surgery, CAMHS, social care etc.)

(if applicable)

Gender and preferred pronouns

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 referred

The 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 Country

Age(Required)

Please enter a number from 0 to 100.

Date of Birth(Required)

Gender and Pronouns

Contact 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

If yes, please give details.(Required)

Which GP Surgery are you registered with?(Required)

Do you take any prescribed medication?(Required)

Yes

If yes, please give details.(Required)

Are there any other agencies supporting you?(Required)

Yes

If yes, please give details.(Required)

Are you in Education?(Required)

Yes

If yes, please state the name of the school or college.(Required)

Where did you hear about YES?(Required)

Section 3 – Reason for Referral

Please indicate the reason(s) for this referral.

Please give as much detail as possible.(Required)

Presenting Issues (please tick any of the following which apply)

Anxiety

Behaviour

Bereavement

Bullying

Depression

Eating disorder

Family conflict

Friendship issues

Gender identity or sexual orientation

Neurodiversity

School issues including school avoidance

Self-harm

Suicidal thoughts

Trauma

Please include any other information which might be helpful.

Is there any other information you want us to know?(Required)

Section 4 – Consent to access and share information

This 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 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.

Paid-for Counselling Service Form

Paid-For Counselling service | Request for Support

Section 1 – Referrer details

Section Two – Person being referred

Section 3 – Reason for Referral

Section 4 – Consent to access and share information

Paid-For Counselling service | Request for Support

Section 1 – Referrer details

Section Two – Person being referred

Section 3 – Reason for Referral

Section 4 – Consent to access and share information

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