MILES FOR SMILES NEW REFFERAL FORM (FROM 2025 onwards)

PLEASE NOTE ; ALL PARENTS ARE ASKED TO CONTRIBUTE £10 PER SESSION TO THEIR ALLOCATED THERAPIST (unless agreed with your therapist).

Parent/ Guardian Name:*

First NameLast Name

Parent/Guardian Phone number*

Area CodePhone Number

Parent /Guardian email address*

example@example.com

NAME OF CHILD: *

First NameLast Name

Childs date of birth*

Date

Childs home address (if more than one address, the one used most often)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

CHILDS GP (Doctors) NAME*

First NameLast Name

CHILDS GP (Doctors) Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PLEASE PROVIDE DETAILS OF ALL DIAGNOSED MEDICAL CONDITIONS OR MENTAL HEALTH CONDITIONS AND ALLERGIES

Please list all medications and supplements your child takes

include dosage and how often.

Has your child ever been hospitalised for mental health problems?*

YesNOUnsure

Has your child got any history of self harm or suicide attempts?*

YesNOUnsure

if you answered yes to the hospitalisation or self harm questions please provide details:

if you answered no please move on to the next question

Has your child tried therapy before?*

YesNOUnsure

if your child has tried therapy previously please give details here:

Tell us in your own words: why you are seeking therapy for your child?*

How long has this been an issue?*

(when did your child first start having these issues)

Please select any of the emotional or behavioural symptoms that apply to your child*

Tell us about anything that makes things worse (triggers)

Is there anything that your or your child feel helps deal with symptoms?

what do you want to achieve during the course of therapy?

TELL US ABOUT ANY PREVIOUS THERAPIES, SELF HELP STATEGIES OR OTHER SERVICES YOU HAVE RECIEVED

EXAMPLE: i have tried hypnotherapy and it helped, i didn't find talking therapy worked for me.

Parental Consent for Therapy

By submitting this form, you are giving permission for your child to receive therapy. Please read the following carefully.

1. Responsibilities of the Parent/Guardian

Once a therapist is assigned, you must arrange sessions based on their availability.
If you don’t contact the therapist or miss sessions, your case may be removed from the program.

Ensure your child attends and participates in therapy.
Inform the therapist of any major changes that may affect therapy.

2. Assigned Therapist

The therapist will confirm their availability and booking process with you directly.

3. Sessions & Initial Consultation

Therapy includes 7 sessions.
An initial consultation may take place via phone before your first session or may be done in person at your first session.

The consultation counts as part of the 7 sessions.

4. Scheduling & Cancellations

You must give at least 48 hours’ notice to reschedule or cancel a session.
If you cancel with less notice, the session may be lost, and a fee may still apply.
Repeated missed sessions or no communication may result in therapy being withdrawn.

Always inform the therapist if you can’t attend a session.

5. What Therapy Involves

Therapy does not replace medical treatment or professional psychological care.
Results depend on your child’s engagement, abilities, and any underlying conditions.

6. Confidentiality & Safeguarding

Sessions are private, except in cases where the child’s or others’ safety is at risk.
Therapists follow strict professional safeguarding and ethical guidelines.

By submitting this form, you agree to these terms.

PLEASE BE AWARE THAT ALL PARENTS ARE ASKED TO CONTRIBUTE FINANCIALLY TO SESSIONS. IF YOU ARE NOT ON BENEFITS OR LOW INCOME, YOU WILL BE ASKED TO PAY THE THERAPIST OR MILES FOR SMILES THE FULL (BUT HIGHLY REDUCED RATE) COST OF SESSIONS. This allows us to make sure funds go to where they are most needed and to enable us to help more people. Funds are, unfortunately not unlimited. £10 PER SESSION IS PAYABLE DIRECTLY TO THE ALLOCATED THERAPIST IF YOU ARE ON LOW INCOME OR BENEFITS. (If you are facing serious financial hardship please discuss with your therapist)

PARENT/GAURDIAN SIGNATURE

MILES FOR SMILES REFFERAL TO THERAPIST

Parent/ Guardian Information:

Childs Information:

CHILDS HEALTH

Why are you seeking Therapy support?

YOUR EXPECTATIONS AND RESPONSIBILITIES DURING THERAPY

TERMS OF SERVICE AND PARENTAL CONSENT