Referral Form for Children or Young Persons under 18

Date of referral
Client Surname: / Client First Name:
Date of Birth: / Gender: / Male / Female / Other
Client Address: / Is it safe to write to this address? / Y / N
Home # / Is it safe to call? / Y / N / Is it safe to leave a message? / Y / N
Mobile # / Is it safe to call? / Y / N / Is it safe to leave a message? / Y / N
Work # / Is it safe to call? / Y / N / Is it safe to leave a message? / Y / N
Email: / Is it safe to email? / Y / N
Parent/Carer/Contact Person:
Address for Parent/Carer/Contact Person:
(if different from above)
Who should contact be made with?
Please include details if different from above.
Name/s of people with parental responsibility:
Any parental dispute? / Y / N / If ‘yes’, please give details:
Do both parents agree to this child receiving counselling? / Y / N / If ‘no’, please give details:
Is the Child / Young Person aware of this referral? / Y / N
Referrer Details:
Self-referral /  / Contact details (only if different from above):

Family Member

/  / Contact details (only if different from above):
Agency /  / Name of organisation:
Name of referrer:
Address:
Contact phone number/s:
Email:
Is the client experiencing any of these issues / Mental Health Issues / Y / N
Domestic Abuse / Y / N
Drug Abuse / Y / N
Alcohol Abuse / Y / N
Behavioural Problems / Y / N
Any other issues?
Please give details.
Please give names and contact numbers of any other professionals involved with this child / young person:
Role / Agency / Name / Contact Number
Please ensure details of any social services involvement are included in this section.
Is this child / young person on the child protection register? / Y / N
Is this child / young person a ‘Child In Need’? / Y / N
Does this child / young person have any additional or special needs? / Y / N
Is this a ‘Looked-After’ Child? / Y / N
If yes, please give details:
Please explain the reason for referral:
Please continue on a separate sheet if necessary.
Any other relevant information:
Referral Status (please tick) / URGENT / NON-URGENT
Please indicate where you would prefer to have appointments:
Merthyr Tydfil
Swansea
Cardiff
Carmarthen
Newport
Bridgend
Aberystwyth
Newtown

Please email to

Or return to:

For counselling in: / Please return to:
Newport, / New Pathways, 20-21 High Street, Newport, NP20 1FW
Cardiff, / New Pathways, 19 St Andrews Crescent, Cardiff, CF10 3DB
Merthyr / New Pathways, 11 Church Street, Merthyr Tydfil, CF47 0BW
Aberystwyth, Newtown, Carmarthen, Swansea, Bridgend / New Pathways - Mid Wales RSC 46 Great Darkgate Street, Aberystwyth, SY20 1DE

New Pathways – Monitoring Form

Client Reference number______

Client GenderM ______F ______Other ______

How old are you? (please tick one category)

Aged 10 or under
11-15
16-17
18-24
25-34
35-44
45-54
55-64
65-74
75 or older

What is your ethnicity? (please tick one category)

White British
White European
Mixed / Multiple ethnic groups
Asian / Asian British
Black / African / Caribbean / Black British
Other Ethnic Group
I prefer not to say

What is your religion?

No religion / Hindu / Sikh
Christian / Jewish / Any other religion
Buddhist / Muslim / Prefer not to answer

Do you have a disability?

Yes, I have a disability / I do not have a disability / I prefer not to answer

1/4