STEP 2 Counselling Referral Form

Step 2 Young People's Health

Counselling referral for young people (11-25 year old)
(Please note if young person is adopted then we are not able to offer counselling)
Referral date*

DayMonthYear
Date
About the referrer
Name of person referring*
Organisation of referrer
Contact number*
Email *
example@example.com
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About Young Person being referred
Full Name*
Preferred Name
Date Of Birth*
Date of birth*

DayMonthYear
Date
Address*
Postcode*
GP Surgery*
What is your gender identity?*
Is your gender identity the same as sex assigned at birth? *
Do you identify as transgender?*
What are your pronouns:*
What is your ethnicity*
What is your religion?*
Are you disabled or do you identify as a disabled?*
What is your sexual orientation*
School/Place of education*
Are you looked after? (if under 18)*
Are you leaving care of have been in care?*
Are you a carer for anyone? (if under 18)*
Preferred Contact for Appointment
Phone number*
Email address
Name of person (if not the young person referred)*
Relationship to the young person*
Are you happy for us to leave messages via text or voicemail to this number?*
Pronoun: (e.g. she/he/they/other)
Ethnicity*
Sexual orientation*
Is the child/young person in Looked After Care? Yes/No
Is the child/young person under a child protection plan? Yes/No
Is the child/young person adopted? Yes/No
Is the child/young person a carer? Yes/No
Is the child/young person a care leaver? Yes/No
Is the child/young person on the edge of care? Yes/No
Is the child/young person's case open to Children's Social Care? Yes/No
Reasons for referring
Please provide brief details of any relevant health related issues or additional needs that may be relevant:
Please provide details of other agencies or services young person/family is involved with or other support currently in place:
Has the young person had any previous counselling? If so please provide brief details.
Please state reasons for your referral to counselling with Step 2: *

0/90
Young Person's Signature required to say:
- I am informed and aware of what counselling is and I give consent to this referral.
- I consent to Step 2 storing and processing the information I have provided in line with Step 2's privacy notice www.step2.org.uk/privacy
Signature (Young Person)*

Clear
Thank you.

If you need to speak more about your referral or have any queries, please contact us at counselling@step2.org.uk or call 01274 720 185.
Should be Empty:

Step 2 Young People's Health

About the referrer

About Young Person being referred

Preferred Contact for Appointment

Reasons for referring