Young People Referral

Young Person Referral Form 

This form is for young people to get support from us and can be completed either by the young person (age 13 and above) or an adult on their behalf.

 

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

Full name

Date of Birth (dd/mm/yy)

Age

Current address

Living Arrangements

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

Are they aware of this referral ?

Contact Number and Contact Name (for when an appointment is offered)

Permission to Contact by Letter (if needed)

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 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

Please let us know, briefly, why the young person would like to see a counsellor? (N.B. Information provided may be shared with the young person)

Are there any issues relating to: (please pick all that apply)

School/College (if appropriate)

Please choose either Atherton or Golborne as the chosen place for counselling and if the young person can travel to either, then please choose both as they may be seen quicker. PLEASE NOTE that young people can ONLY be seen in school when school are paying for Willow’s services.

Optional Paid Service

As a charity we believe that all children and young people should have access to free counselling. However, we don’t currently have enough money to see everyone quickly and this is the reason we have such a long waiting list. For parents/carers who would like to reduce this waiting time, you can do so by paying for the counselling sessions. If this is the option that you would prefer, please tick below and a member of the team will be in touch with you shortly to discuss it further.

Please indicate whether you wish to pay for the child/young person's counselling.

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)