Washington Mind Young People’s Project Self-Referral (Ages 11 to 18)

Washington Mind Young People’s Project Self-Referral (Ages 11 to 18)

(for referring yourself to counselling)
Please complete the form below with as much information as possible.

If you are at risk to self/actively suicidal with plan, please ADVISE A&E IMMEDIATELY or contact the Children and Young People’s Crisis Team via the NHS 111 Mental Health Team which can be reached by calling: 111 and dialling option: 2
About you

We need a little bit of information about you. Please be as honest as you can, and fill in as much as you are able to.
Your name*

First NameLast Name
What name do you like be called?
Your email address (if you have one)
example@example.com
Your phone number*
Please enter a valid phone number.Format: 0000 000 0000.
YesNo
YesNo
How old are you?
Which school or college do you go to? (If you're home-schooled or have left school please let us know in this space:*
What's the name of your parent or carer:
Why would you like to talk to a counsellor?

Everyone has different reasons for wanting to talk to a counsellor, and all reasons are okay. Maybe things feel tough at home or school, or perhaps you've been feeling worried, sad, or anxious about things. Our feelings thoughts and behaviours are a response to our situation, and talking about it can help us work out what will help.

We dont expect you to tell us everything about your life, just the things that you feel ok to speak about. Asking for help is a really brave thing to do, and we're here to listen and help you find ways to cope with difficult emotions and situations.
Your reasons:
Should be Empty:

Washington Mind Young People’s Project Self-Referral (Ages 11 to 18)

About you

Why would you like to talk to a counsellor?