Referrals

This page contains a young person’s referral form and an adult’s referral form. Before filling out the referral form we have provided both young people, and parents/carers with some information about the service and what is offered.

Young People

It can be hard asking for and getting help when you’re struggling with issues, so you’ve made the first step in helping yourself by visiting our website. Before you make the next step, here’s a little bit about what counselling is and how Willow works.

First of all, we are a confidential service and if we think that you’re old enough (usually around the age of 13) and counselling is the right type of help for you, then you can get help from us without your parents/carers or anyone else knowing. We would only let someone know that you’re getting support from us if we thought that you or someone else that you told us about were in danger. If we don’t think that you’re old enough, then we would need permission from whoever looks after you before you could start getting help from us.

When you start seeing a counsellor, it will just be you and them, with the counselling session lasting for 50 minutes. They will see you either at our main base in Atherton or at Platt Bridge and they will see you at the same place, time and day each week for as long as you need support from them.

The way that we work is that you talk about the things that are important to you without us judging or telling you what to do.

If you don’t think that counselling is for you, then there are other things and ways to help yourself. Take a look at the TLC section’s ‘Ways to help yourself’.

If you do think that counselling is for you, fill in the referral form on this page, and we will put you on our waiting list but you need to know that at the moment, it’s very long so you may have to wait a while. If you’re aged 12 and over you can come along to our weekly group on Mondays in Atherton from 6-8pm. If you fancy this, then please ring us up first to see if we have any places, as it’s only a small group (and very welcoming!).

Young Person Referral Form

Step 1

Personal Information

Step 2

Living Arrangements

Step 3

Health and History

Step 4

History

Step 5

Contact Information

  • Step 1
  • Step 2
  • Step 3
  • Step 4
  • Step 5

Personal Information

Name

Date of Birth

Age

Address

Living Arrangements

Who does the child / young person live with and name?

Are they aware of this referral ?

Permission to Contact

If by Phone, who is it and the Number ?

Health

Doctors Surgery / Phone

Please state any health issues

Does the child/young person have any disability/access needs?

If Yes, please specify here

History

Has the child/young person ever been referred to CAMHS?

If yes, please give details

Are you aware of any child protection issues?

Is the child/young person known to social services?

Is the child/young person known to the police?

Is anybody in the family currently in or has been in any of the armed forces?

Is the child/young person a carer for any family member?

Contact Information

Name and contact details of the person making this referral

If referral is from an agency or other professional, name of agency or organisation and address

What has triggered this Referral (NB Information provided will be shared with client)?

Are there any issues relating to (please circle)

School/College Attended (if appropriate)

Preferred place for counselling, please circle

Data

By ticking the box below and printing your name, you are agreeing to Willow Project storing data of all persons named on this form in line with our Data Protection Policy and Privacy Notice, details of which can be obtained from Willow Project on 01942 679300

Please print the name of the Young person or Parent/carer (if under 13 years old)

 

Parents/Carers

It can be difficult trying to support children and young people by yourself, but you can get support for them and also support for you too at Willow Project.

You can refer your child/young person to us yourself without any other professional getting involved, such as your doctor or school, as long as the young person knows that you have referred them and they want to come. All that you need to do is fill in a referral form and it will come straight to us and this can be found at the top of the page when you click on the header. We will then add them to our waiting list, but you need to know that this is very long and it could be some time before they are seen. We are a charity and rely on donations, so we don’t always have enough money to see everyone that’s waiting to see a counsellor (If you would like to pay privately for sessions, then this can be arranged and would alleviate the waiting time. Please contact the office for further details).

If the young person is aged 12 and over they can come along to our weekly group on Mondays in Atherton from 6-8pm. Please contact the office to see if there are any places on 01942 679300.

Emotional and mental health issues can impact on others in the family and if you are struggling yourself, then as a parent/carer of a young person that has been referred to us, you can access our adult service. The referral form for this is also at the top of this page and can be found by clicking on the header. All adults are seen on a separate evening to young people, so that confidentiality can be maintained, which means that your child wouldn’t know that you are accessing us, unless you choose to tell them.

All counselling sessions, whether for a young person or yourself are one to one, last 50 minutes and are at the same place, time and day every week. We only offer individual counselling, so families can’t be seen together.

Adult Referral Form

Step 1

Personal Information

Step 2

Health and History

Step 3

Contact Information

  • Step 1
  • Step 2
  • Step 3

Personal Information

Name

Date of Birth

Gender

Address

Email

Telephone

Health

Doctors Surgery / Phone

Please state any health issues

Do have any disability/access needs?

If Yes, please specify here

Referral Information

If this referral form is being completed by another agency or professional, please give contact details and name of the organisation

Please give a brief description of what has triggered this referral

Data

By ticking the box below and printing your name, you are agreeing to Willow Project storing data of all persons named on this form in line with our Data Protection Policy and Privacy Notice, details of which can be obtained from Willow Project on 01942 679300

Please print the name of the person making this referral