Please put the details of the child, their needs and the reason for the referral within this form.
This type of counselling is for children aged between the ages of  3-11  or if they have a learning disability and youth counselling would not be suitable for them.

If the child is above this age range or does not have a learning disability, please complete a young person referral instead.

Please note that all questions that have a red * next to them are required information, so you will not be able to move onto the next section of this form without completing these questions. Once you have answered all questions, please press the submit button and we will receive your referral.

Once, we have received your referral, we will make contact to complete an initial assessment.