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Telephone : 01905 972433

Text : 07895 796857

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Child / Young Adult Counselling Referral Form

Online & Telephone appointments available within 7-days.

Appointments are charged at £35.00

Child's Name

Gender

Boy

Girl

Other

Child's Email (If applicable)

Date of Birth

Child's Phone (If applicable)

Town

Parent/Guardian/Referrer Name

Parent/Guardian/Referrer contact Email

Parent/Guardian/Referrer Phone

Relation

Parent

Guardian

Other (Please specify in additional information)

Additional information:

Reason for seeking therapy?

Has the child been formally assessed or diagnosed with:

Are you currently receiving or awaiting support from elsewhere?

Please select if...

You are or have in the last 2 years experienced suicidal ideations or feelings of wanting to self-harm

You have previously attempted suicide or self-harmed (within the last 2 years)

Which day(s) are you available?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Which time(s) are you available?

Morning (9am-noon)

Early Afternoon (noon-3pm)

Late Afternoon (3pm-6pm)

Evening (After 6pm)

Please confirm if you have a preference on the counsellor's gender

Male

Female

Please confirm your preferred session method(s)

Telephone - £35.00

Video (Google Meet) - £35.00

Where did you hear about us?

Other:

I am happy to receive information about Mental Health (Support, News, & Resources) from TCS in the future.

Before you submit your referral please tick here to consent to storage and processing of your data

07895 796857

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