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Dialogue Confidential Referral Form:
Primary School

Dialogue Confidential Referral Form: Primary School

"*" indicates required fields

Date of referral*

DD slash MM slash YYYY

School Name*

Child's Name*

First Last

Date of birth*

DD slash MM slash YYYY

Age

Gender

Ethnicity

Class & Year Group*

Class Teacher's Name*

First Last

Class Teacher's Email

Parent(s) / Carer(s) Name*

First Last

Parental Responsibility?*

Yes

If 'No', why not?

Are both parents aware of this referral?

Yes

Parent(s) / Carer(s) Phone Number (Mobile)*

Parent(s) / Carer(s) Phone Number (Home)

Parent(s) / Carer(s) Email*

Parent(s) / Carer(s) Home Address*

Street Address City Post Code Country

Other Parent(s) / Carer(s) Name (if different from above)

First Last

Parental Responsibility?

Yes

If 'No', why not?

Other Parent(s) / Carer(s) Phone Number (Mobile)

Other Parent(s) / Carer(s) Phone Number (Home)

Other Parent(s) / Carer(s) Email

Other Parent(s) / Carer(s) Home Address (if different from above)

Street Address City Post Code Country

Parental Consent

We must have consent before therapy can start. Please confirm that you have received consent for this referral from the parent/carer*

School has obtained written consent for counselling

School has obtained verbal consent for counselling

Next of Kin (if not parents):

Name, Mobile Number, Address

If the child is in care - social worker details:

Name, Mobile Number, Address

Who initiated the request for counselling?*

School

Parent

Child

Other

You answered 'Other', please indicate who

Reason for referral

About the child

Is the child in care?*

Yes

Is the child adopted?*

Yes

Adoption Support Fund applied to?*

Yes

Is there a safeguarding plan in place?*

Yes - Child Protection Plan

Yes - Child in Need Plan

Other

Please give details

If YES - CP Plan, what category?

If YES - CP or CIN Plan, please give the Social Worker/Key Worker contact details:

EHC Plan?*

Yes

Are there any learning difficulties / disabilities?*

Yes

Unknown

If 'YES', please enter the type of difficulty / disability:

Are there any known medical conditions?*

Yes

Unknown

If 'YES', please enter type of condition:

Is the child taking any prescribed medication?*

Yes

Unknown

If 'YES', please enter details of medication:

Does the child have a diagnosis? E.g. autism, ADHD*

Yes

Unknown

If 'YES', please enter details:

Is the child known to deliberately hurt themselves?*

Yes

Unknown

If 'YES', please enter details:

Is the child known to express feelings of hopelessness or wishing they were no longer here?*

Yes

Unknown

If 'YES', please enter details:

Family Background*

Including, if known, any health issues, bereavement, domestic violence, offending, substance use etc.

Other agencies / professional involvement?*

e.g. CAMHS, Children’s Services, Police etc.

What is the relationship like between the school and the child’s parents / carers / family?*

Does the child receive any additional support in school?*

If you have any other information that may be helpful for the counselling service to know, please give details below:*

Counsellor's Email Address*

Due to privacy considerations ymcadlg.org addresses only please. Use of email addresses outside this domain will result in form information being lost.

Comments made about the service are sometimes used in promoting our work but will remain anonymous.

Please add your email address here if you would like a copy of this referral form

Name

This field is for validation purposes and should be left unchanged.

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YMCA DownsLink Group

YMCA DownsLink Group
Reed House
47 Church Road
Hove
BN3 2BE

Registered Company No: 3853734
Registered Charity No: 1079570
Social Landlord No: 4644

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Dialogue Confidential Referral Form:Primary School

Dialogue Confidential Referral Form: Primary School

Parental Consent

About the child

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Dialogue Confidential Referral Form:
Primary School