First name
Last name
Address 1
Address 2
Address 3
Address 4
Postcode
Email address
Mobile phone
Phone number
By post
By email
By mobile
By text message
Other information
Is the young person aware of this referral
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Yes
No
Date of birth
Gender
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Male
Female
Trans Gender
Other
Ethnic identity
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Arab
Asian/Asian British: Bangladeshi
Asian/Asian British: Chinese
Asian/Asian British: Indian
Asian/Asian British: Other
Asian/Asian British: Pakistani
Black/Black British: African
Black/Black British: Caribbean
Black/Black British: Other
Mixed: Other
Mixed: White and Asian
Mixed: White and Black African
Mixed: White and Black Caribbean
Other Ethnic Group
Prefer not to say
White: British
White: Irish
White: Other
What day(s) and period(s) would be best for this student to see a Counsellor
Why does the person being referred want Counselling?
Has the person being referred had any experience of Counselling in the past?
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Yes
No
If yes please give details
Has the person being referred been diagnosed with any mental health conditions?
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Yes
No
Details of any mental health diagnosis
Is the person being referred feeling suicidal?
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Yes
No
Does the person being referred have a diagnosed eating disorder?
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Yes
No
Does the person being referred have a history of self harm?
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Yes
No
Are their any issues with drugs or alcohol consumption?
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Yes
No
If you have answered yes to any of the questions above please provide details here
Is the person being referred Autistic?
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Yes
No
Awaiting diagnosis
Does the person being referred have ADHD
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Yes
No
Awaiting diagnosis
Name of Referrer
Email address of Referrer
Relationship of client to referrer
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Parent/carer
Social worker
Family worker
School staff
GP
Health professional
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