Referrer Name *

Referrer Number *

Referrer E-mail *

Is the Referrer the Emergency Contact? Is the Referrer the Emergency Contact?YesNo

Emergency Contact Name (if not same as above)

Emergency Contact Number (if not same as above)

Emergency Contact E-mail (if not same as above)

Does the Parent/Carer know of the referral? Does the Parent/Carer know of the referral?YesNo

Parent/Carer Name (if not same as above)

Parent/Carer Number (if not same as above)

Parent/Carer E-mail (if not same as above)

Client Full Name *

Date of Birth *

Gender * Gender *HeterosexualHomosexualLesbianGayBi-SexualA-Sexual

Is the clients gender identity as at birth? * Is the clients gender identity as at birth? *YesNo

Ethnicity *

School / Workplace *

Home E-mail *

Home Address *

Home Contact Number *

Mobile Number *

Do you have any concerns about being contacted in these ways? *

GP Name *

Surgery *

NHS Number (not compulsory)

Any illnesses or allergies *

Is the client OK if we need to contact them? * Is the client OK if we need to contact them? *YesNo

Is the client taking any medication?

Does the client have any known illnesses?

Does the client see any other Specialists? (Please provide details)

Do any of the following Health, SEND or disability categories apply to the client? (Select all that apply) Do any of the following Health, SEND or disability categories apply to the client? (Select all that apply) Autism / ASD with a diagnosis Autism / ASD on pathway to diagnosis Attention deficit hyperactivity disorder (ADHD) with a diagnosis Attention deficit hyperactivity disorder (ADHD) on a pathway to a diagnosis Learning Difficulties Specific Learning Difficulties (SpLD) eg Dyslexia or Dyscalculia Sensory Processing Difficulties Visual Impairments Hearing Impairments Physical Disability

Is there any other health, SEND, disability information you would like to share?

What issues is the client presenting with (Select all that apply) What issues is the client presenting with (Select all that apply) Abuse Alcohol/Drugs Anger Management Anxiety Bereavement/Loss Bullying Depression Eating Problems Family Problems Gender Identity Low Mood Low Self Esteem OCD Online Safety Personal Relationships Physical Health Self Harm Sexuality Suicidal Thoughts Trauma

Please provide any additional information that you think may help us understand the young person's current difficulties, including how long they have felt this way

Are any other agencies involved with the young person? e.g. social worker, CAMHS

How do you wish the counselling to take place? (Face to face, online, telephone, In school, CHAT counselling office, other - please specify)

Any other information (Please expand as necessary)

Once form is complete, solve the simple sum and select Submit. Please be advised that all the required * fields must be completed before submitting