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Children's & Young People's Counselling Referral

Please fill out the following form.

All information will be treated as confidential.

Only use this form for referrals for under 18's

N.B. Only a person with parental responsibility can make a referral

Jan 2026 - We are only taking childrens referrals for private (paid) counselling at present

Child's First name*

Child's Last name*

Date of birth*

Day

Month

Year

Address*

Name of person making referral - *

Relationship to the child or younng person - *

Email*

Phone*

I confirm that i hold parental responsibility for this person or a court order/interim order is in place of the child

Is the child / young person aware of this referral (where age appropriate) and in agreement?*

Which Health Trust are they under?*

Northern Trust

Belfast trust

South Eastern Trust

Western Trust

Southern Trust

Please provide us with the name of the child's GP practice & address (this is for gathering service statistics)*

Are there any other agencies involved at present? Such as social services, PSNI, youth justice*

Is the child neurodivergent or are their suspicions of ASD, ADHD, Tourettes, Dyslexia, Dyscalculia or any other neurotype?*

Autism

ADHD

Dyslexia

OCD

Dyspraxia

N/A

Awaiting assessment

Other

Do they have any diagnosed or undiagnosed mental health conditions?*

Diagnosed

Undiagnosed

Please provide as much information as possible (MH)

Do they have any physical health conditions?*

Yes

Please provide as much information as possible (PH)

Tell us about what is going on now / in the past that you feel counselling will help with.*

Please tell us how you heard about our service*

A member of our team will ring you to complete a referral form and an assessment will be required to ensure suitability for our service.

We are running an extremely busy service and aim to get in touch with you as soon as possible. I understand this is not a crisis service and in an emergency i will contact one of the services listed below for immediate support.

Permission to contact

A Safe Space to be Me

info@asafespacetobeme.co.uk

028 9620 8284

Safeguarding Policy

Equal Opportunities Policy

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