Child Counselling Referral Form - Ages 6-17 Years

For clients aged 18+, please complete the Adult Counselling Referral Form on the previous page.

Online and Telephone counselling appointments available within 24 hours.

Appointments are charged at £40 per session.

Child's name

Sex (as registered at birth)

Pronouns

Gender

Child's date of birth

Child's email (if applicable)

Child's phone (if applicable)

Town

Parent/Guardian/Referrer name

Parent/Guardian/Referrer email

Relation

Reason for seeking therapy

Has the child been formally assessed or diagnosed with

Are you currently receiving or awaiting support from elsewhere?

Additional information:

Please select if:

The child is or has in the last 2 years experienced suicidal ideations or feelings of wanting to self-harm

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

Please confirm if you have a preference on the gender of your counsellor

Male

Female

No preference

Please confirm your preferred session method(s)

Telephone

Video (Google Meet)

Where did you hear about us?

Other:

I am happy to receive information about mental health (support, news and resources) from TCS in the future

Online and Telephone counselling appointments available within 24 hours.

Appointments are charged at £40 per session.

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

Child Counselling Referral Form - Ages 6-17 Years

For clients aged 18+, please complete the Adult Counselling Referral Form on the previous page.

Online and Telephone counselling appointments available within 24 hours.

Appointments are charged at £40 per session.

Child's name

Sex (as registered at birth)

Child's date of birth

Child's email (if applicable)

Child's phone (if applicable)

Town

Parent/Guardian/Referrer name

Parent/Guardian/Referrer email

Reason for seeking therapy

Has the child been formally assessed or diagnosed with

Are you currently receiving or awaiting support from elsewhere?

Additional information:

Please select if:

The child is or has in the last 2 years experienced suicidal ideations or feelings of wanting to self-harm

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

Please confirm if you have a preference on the gender of your counsellor

Male

Female

No preference

Please confirm your preferred session method(s)

Telephone

Video (Google Meet)

Where did you hear about us?

I am happy to receive information about mental health (support, news and resources) from TCS in the future

Online and Telephone counselling appointments available within 24 hours.

Appointments are charged at £40 per session.

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