restoring wellbeing through contact

Child & Young Person Referral form

To make a referral, please fill in the online form below or click here to view the information about referring a child or young person to Lifeline.

Please fill out the following form(s) and click send. Only designated Contact staff will have access to this information. View our privacy policy for more information. 

Please complete both referrer details and client details below if you are referring someone on their behalf. If you are referring yourself, only complete client details section.


Referrer Details


Relationship to referred child/family.

Contact number


Please continue to client details section to
complete the referral.

Child/Family Details

First name

Last name

Date of birth

Full Postal Address

Tel. Number

Mobile Number

Please include your mobile number as we may be able to offer initial appointment at short notice.

Has the child/family consented to your referral?
Yes No

Have the family / child indicated they a willingness to attend appointments?
Yes No

GP information

Who is in the family?

What event(s) have led you to make a referral to Lifeline

What are your concerns about the child/young person's wellbeing?

For what period have your concerns persisted?

Are any family members on the Child Protection or Vulnerable Adult Registers?

In what ways do you believe 6 sessions of Brief Solution Focussed Individual Counselling or Family Intervention would be useful to the child/young person?

Please describe any other event(s) that have caused distress to this child/young person or family in the past?

Is the child/family receiving any other services at present?
Yes No

If yes, please identify and provide contact details

Is there anyone else involved with the child/young person or family that you think it would be helpful for us to know about?
Yes No

If yes, please provide contact details

Any other information you would like to share with us?

How did you become aware of services provided by Contact/Lifeline?

Please note all information that you provide will remain confidential. We will not make contact with any other professional or organisation without your consent.

send submit