CLICK HERE TO MAKE A CHILD OR YOUNG PERSON REFERRAL
To make a referral, please fill in the online form below or download the General Referral Form, which can either be posted or faxed to our Head Office.
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
Referrer
Is the person aware that this referral is being made?
Contact name
Email Address
Contact number
Address details
Please continue to client details section to
complete the referral.
Client Details
First name
Last name
Date of birth
Male Female
Reason for referral
EG. Directly or indirectly affected by depression, bulling, suicide, family conflict, drugs or alcohol problems, school problems, sexual identity, other…
Preferred contact number
If you would like to hear from one of our counsellors please fill in a number they can reach you on.
What time is most suitable to hear from a counsellor
We aim to call you within 48 hours of receiving your referral.
Would you like to receive information in the post?
Yes No
Address details
Where did you hear about our service?
Have parents been informed of referral?
Yes No
Special needs / any other relevant information
GP information
Please remember you can call our 24/7 helpline on 0808 808 8000 and speak directly with a counsellor.