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.
Personal Information Living Arrangements Health and History History Contact Information
Date of Birth (dd/mm/yy)
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 ?
Doctors Surgery / Phone
Please state any health issues
Does the child/young person have any disability/access needs?
If Yes, please specify here
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?
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
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)
Health and History