Client Name / DOB / AGE
__/__/__
Gender
M/F / Ethnicity
(See page 3 for codes) / Medical Condition
(Please provide details) / Disability
(Please provide details)
Client Address
Tel / Mob / E-mail
Parent/Carer Name: / Relationship
(Address if different from above)
Tel / Mob / E-mail
Availability to attend counselling
Preferred Venue / Hanley / Newcastle / Biddulph / Any
Client referred previously / Y / N
Has the client consented to referral / Y / N
Are Parents/Carers aware of referral / Y / N
GP Name and address
Is This Child/Young Person in Care? (If YES please give details below) / Y/ N
Local Authority (Foster Care/Residential Care) / Area
Private (Foster Care/Residential Care) / Area
Looked After (Other) / Please State
Leaving Care
How did you hear of Younger Mind?
(if via a G.P or Health Worker please provide details) / GP/HW Name
Practice Name
School / Tel
Training / Tel
Employment / Tel
NEET / Other
Referrer’s Details / Self Referred / Family Referred
Outside Agency Name
Address
Name & Position of Referrer
Contact Tel No / Mobile
E-mail Address

OTHER AGENCY INVOLVEMENT OR OTHER WORK UNDERTAKEN

(PLEASE NOTE ANY CHILD PROTECTION/SAFEGUARDING ISSUES/INTERVENTIONS):

Please
 / Detail(If applicable)
CP
CAF
CIN
OTHER

MAIN ISSUES – Please tick one or more as appropriate

C1 / Self Harm
F1 / Anxiety
F2 / Low Mood
J1 / Substance Misuse
K1 / Loss or Bereavement
K3 / Bullying
K5 / Illness of Self
K6 / Illness of Others
L2 / Anger
L3 / School Issues/ Refusal
M3 / Family Breakdown/Relationship
M5 / Neglect Abuse
O / Behavioural
O / Domestic Violence
O / Issues Around Sexuality
O / Pregnancy or Related Issues
O / Relationships
O / Self Esteem

ANY OTHER INFORMATION THAT YOU MAY FEEL IS RELEVANT – To include any known risk factors regarding this young person and his/her family.

(Please continue on page 3 if required)

YOUNG PERSON’S COMMENTS ON REFERRAL

NB: This Section Must Be Signed by the Young Person. If it is not signed the form will be returned to you.

*Would you be interested in participating in Group Work to look at your concerns rather than One to One Counselling? YES / NO
Young Persons Signature: …………………………………………….. Date: ………………......

Outside Agency/Parent/Carer Signature: …………………………..… Date …......

Extra information (cont)
White:
White British
White Irish
White European
Welsh
Any Other White Background
Mixed:
White & Black Caribbean
White & Black African
White & Asian
Welsh
Other
Gypsy /Traveller, or
any other ethnic group
English Gypsies
Roma/Romani
Irish Travellers
Other Traveller / W1
W2
W3
W5
W9
M1
M2
M3
M5
M9
O1
O2
O9 / Asian or Asian British:
Indian
Pakistani
Bangladeshi
Welsh
Chinese or Any Other Asian background
Black or Black British:
Caribbean
African
Welsh
Any other Black background
Not stated / A1
A2
A3
A5
A9
B1
B2
B5
B9
NS

SH/Forms/YM- Referral Form1 | Page