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Dialogue Confidential Referral Form:
Secondary School / College

Dialogue Confidential Referral Form: Secondary School / College

"*" indicates required fields

Counsellor Details

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

Student Details

Name*
DD slash MM slash YYYY
Parent(s) / Carer(s) Name
Parent(s) / Carer(s) Address

Current issues including family, school, friendships:
Has this referral been discussed with the young person?*
Have the parents/carers of the young person been involved in the referral process?*
Are there any ongoing Child Protection concerns regarding this student?*
Is the student on the Child Protection Register?*
If YES, please answer the following
What category:
Social Worker contact details:
 
Does the student have an Education, Health & Care Plan?*
Does the student have any known learning difficulties/ disabilities?*
Does the student have any known medical conditions?*
Is the student taking any prescribed medication?*
Does the student have a diagnosis? E.g., autism, ADHD*
Is the student known to self-harm?*
Is the student having suicidal thoughts?*
Has the student made any attempts to end their life of which you are aware?*
Does the student receive any other school support e.g. learning mentor / pastoral support?*
Any history of conflict between parents/families/carers and school staff?*
Are they currently receiving private therapy?*
Are they under any CAMHS teams, including the Duty Team?*
Are any other services working / have worked with this student?
Social Services*
GP*
YOT*
Police*
Educational Psychologist*
Early Help*
Other Service (enter details below):*
Comments made about the service are sometimes used in promoting our work but will remain anonymous.
This field is for validation purposes and should be left unchanged.

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YMCA enables people to develop their full potential in mind, body and spirit. Inspired by and faithful to our Christian values, we create supportive, inclusive and energising communities, where young people can truly belong, contribute and thrive.

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