Children and Young People’s Counselling Referral Form

Child/Young Person's Name

Date of Birth

Age

Parent/Carer Name

Relationship to Child

Address

Postcode

Telephone Number

Email Address

School/College

Reason for Referral

Current Support Services

Risk Concerns

Goals for Counselling

Parental Responsibility Confirmation
I confirm that I have parental responsibility for this child, or have the authority to make this referral on their behalf.

Consent
I consent to this referral being made and to Protea Wellbeing contacting the individuals named above regarding this referral.

Signature (please type your full name)

Date