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info@therapycentreservices.com
Counselling Referral Form
Online & Telephone counselling appointments will
be offered within 24 hours
Name of School
Multi-academy trust
Please select if you are part of a MAT
Central Learning Partnership
Emmaus Catholic Multi Academy Company
Leigh Trust
Our Lady of the Magnificat
The Holy Family of Nazareth Catholic Academy Trust
The Holy Spirit Catholic Multi Academy
The Romero Catholic Academy
Student's Full Name
Gender
Male
Female
Other
Student's Email (if applicable)
Date of Birth
Student's Phone No
Number of sessions authorised
Referrer Contact Name (Headteacher / Safeguarding Team / Teacher)
Referrer Contact Email
Referrer Phone No
Reason for seeking therapy?
Choose an option
Academic concerns / Exam stress
Adoption & Foster care issues
Anger / aggression or tantrums
Anxiety
ADHD (Attention-Deficit Hyperactivity)
Attachment issues
Autism & Asperger's
Bereavement
Blended family issues
Body dysmorphia
Bullying
Cancer
Child abuse
Child neglect
Depression
Developmental issues
Divorce issues
Disruptive Mood Dysregulation (DMDD)
Education related stress
Eating disorders
Family issues
Fears / worries
Feeling sad / SAD
Gender Identity
Giftedness
Health anxiety
Health issues (physical)
Hyperactivity
Insecurity
Insomnia / nightmares / night terrors
Intellectual Disability
Irritability
Mood swings / Mood disorder
OCD
Oppositional & Defiant Behaviours (ODD)
Personality disorders
Phobias
Poverty
Racial / ethnicity
School performance (decline)
Self confidence / self esteem
Self harm / suicidal thoughts
Sibling issues
Social anxiety
Social Media
Trauma
Withdrawal / isolation
Has the student been formally assessed or diagnosed with:
Choose an option
Anxiety
Bi-polar
Body dysmorphia
Hypomania / Mania
Gender identity
Paranoia
PTSD
Personality disorders
Psychosis
Schizophrenia
Other (please specify)
N/A
Session method
Face-to-face (On-site)
Online Video
Telephone
If the sessions are taking place on-site, please confirm the day/time agreed with the student.
Reports Required
Please select..
A) None
B) Initial Report only
C) Initial, Interim, and Final Report
D) Final Summary Report
Please select if...
The student is or has in the last 2 years experienced suicidal ideations or feelings of wanting to self-harm
The student has previously attempted suicide or self-harmed (within the last 2 years)
Additional Information
Consent
Please confirm that you have received formal consent from the student to share their personal information for the purpose of this referral.
If you have any questions at any time, please email:
info@therapycentreservices.com
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