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Northorpe Hall Trust Counselling Service for Young People

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									       Northorpe Hall Trust Counselling Service for Young People
                  53 Northorpe Lane, Mirfield. WF14 0QL Tel: 01924 492183
                  www.northorpehall.co.uk     counselling@northorpehall.co.uk

                                  Please answer all questions

Information about young person being referred:
Name                                           Known as
Address (including
postcode)
Telephone
(including mobile)
Date of Birth
Male / Female
Is the child/young person looked after by the local authority?       Yes/No


Ethnicity: (tick one)
White - British               Mixed White / Black                Asian - Other
                              African
White - Other                 Indian                             Mixed White / Asian
Black - Caribbean             Pakistani                          Any other mixed
                                                                 background
Black - African               Mixed White / Black                Other ethnic group (please
                              Caribbean                          state)
Black - Other

Comments by referrer: Why have you referred this child/young person? If the young
person has any special needs or a disability, please give details of access needs, language
requirements etc.




Comments by the young person: Why do you want counselling? What do you want to talk
about?
Has the young person agreed to this referral being made? (circle one)              YES / NO
Have they been to Northorpe Hall for counselling before? (circle one)              YES / NO
Does the young person have any preference of counsellors gender?                  MALE/FEMALE
Please indicate (female/male or no preference in box)

When can the young person come for counselling in MIRFIELD?
(Appointments last an hour. Circle all that are possible)
      Mon                Tue                   Wed          Thur                         Fri
  9am – 12pm         9am – 12pm           9am – 12pm                                9am – 12pm
    1 – 4pm            1 – 4pm               1 – 4pm      12 – 4pm                    1 – 3pm
                       5 - 7pm               5 – 7pm      5 – 7pm

When can the young person come for counselling in HUDDERSFIELD?
(Appointments last an hour. Circle all that are possible)
        Tue                     Wed                       Thurs                       Fri

       4 - 7pm                   4 - 7pm                 10 – 4pm                  10 – 4pm

Other organisations involved: If the young person is receiving support from other
organisations or professionals, or on a "waiting list" for services, please give brief information




Young person’s main carer / guardian (please list all)
Name(s)
Address(es)


Telephone/Mobile
Is the main carer/guardian(s) aware of this referral?                               YES / NO
Can we discuss this referral with the above carer/guardian(s)?                      YES / NO

Name and contact phone number of person providing transport to counselling




Information about the person making referral:
Name
Email address
Telephone                                                        Mobile
Agency/Organisation
Address
                                                                 Postcode
Relationship to child
or job title as
appropriate

I give my permission for the information above to be used by Northorpe Hall Trust
Signed (referrer)                                        Date


I give my permission for the information above to be used by Northorpe Hall Trust.
Signed (young                                            Date
person)

								
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