Transform Counselling Services - Confidential Referral Form

(Under 16)

To access counselling with TCS, please complete the referral form below. You may self refer or be a parent/carer, professional agency or school to complete this on the client’s behalf. This information is strictly confidential and will be stored carefully in accordance with the Data Protection Act 1998. Following receipt of this referral form, TCS will contact you to arrange an initial assessment.

Name

First Name

Last Name

Date of Birth

YYYY

Gender

Ethnicity

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Parents/Carers

Siblings

Other Significant Adults

Date of Referral

YYYY

Referred By

First Name

Last Name

Referrer Position

Agreement Given

Adult

Yes

Agreement Given

Child

Yes

Other Agencies Involved

Brief history/description of difficulties (including any current concerns):

Brief description of current/past relationships:

Brief Description of disability, inc.medication/treatment (if applicable):

Please describe academic progression:

Please describe the child’s strengths, abilities and special interests:

Any Other information:

Parent/Carer/School Staff: Aims/Expectations of Counselling

Child: Aims/Expectations of Counselling

Referral Completed By

First Name

Last Name

Relationship to Child

Date of Referral

YYYY

Transform Counselling Services - Confidential Referral Form

(Under 16)

Address

Hours

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