Step 2 11-25yrs 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 and under 18 then we are not able to offer counselling)
Which counselling project best suits your needs?
Referral date

DayMonthYear
Date
About the referrer
Name of person referring
Organisation of referrer
Contact number
Email
example@example.com
Would you like to be added to our mailing list to receive updates on Step 2 news, resources and offers?
About Young Person being referred
Full Name
Preferred Name
Date of birth

DayMonthYear
Date
Address
Postcode
GP Surgery
(for 16-25yrs Enhanced Access Counselling only)
GP Surgery (if not listed above)
What is your gender identity?
What are your pronouns:
What is your ethnicity
What is your religion?
Are you disabled or do you identify as a disabled?
Please name disability if applicable
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?
Reasons for referring

IMPORTANT: information written here may be shared with the young person - please indicate whether there is information that you do not wish to be disclosed to the young person.
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
I, the referrer, confirm that I have;

• Informed the young person that I am referring them for counselling with Step 2 Young People's Health
• Young person understands and agrees that Step 2 will receive, process and store their data in line with data protection policies listed on the website (www.step2.org.uk/step2-policies) in order to be referred for counselling.
Tick to confirm the above statement
Signature (Young Person)
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