Haberdasher Askes School

Referral Form – Counselling

(To refer to our other services, use our standard Referral Form)

Young person’s details
Name: / Ethnic origin:
Address: /

Telephone numbers & email:

Gender: Female Male / Date of birth: Age:
Sexual orientation:
Bisexual Heterosexual Lesbian/Gay Man Other Prefer not to say
Doctor’s name, address and tel:
Members of current household including their relationship to the young person:
Other people important to the young person:
Describe any recent changes in the young person’s or family’s life:
Describe important past events:
Explain how urgent this referral is and why:
Has a CAF has been completed for this young person?
Yes No Don’t know
Notes: / Is this young person the subject of a Child Protection Plan or part of the Safeguarding process?
Yes No Don’t know
Notes:
Are there any risks that you cannot disclose to us due to confidentiality/data protection? Yes No
Identified risks to young person / Yes / No / Don’t know
1. / Do they have any issues around literacy/numeracy/sight or hearing problems (eg. dyslexic, learning difficulties)?
Details:
2. / Do they have any issues them affect you physically (eg sickle cell, mobility problems, asthma)?
Details:
3. / Are they at risk of eviction or having a utility cut off (eg rent/service charge arrears)?
Details:
4. / Is their accommodation safe for them and for visitors?
Details:
5. / Have they recently disengaged from any services?
Details:
6. / Do they have a history of, or are they currently using, drugs/alcohol?
Details:
7. / Have they ever experienced bullying, exploitation or harassment?
Details:
8. / Have they ever experienced violence or abuse?
Details:
9. / Are they or have they ever been involved in a gang?
Details:
10. / Are they, or have they ever been the victim of domestic violence?
Details:
11. / Have they ever experienced, are they currently suffering depression or mental health issues?
Details:
12. / Are they currently taking medication?
Details:
13. / Have they ever felt like harming themselves or thought about suicide?
Details:
14. / Are there any other individual factors that affect them (eg causes of stress, relationships)?
Details:
Identified risks to others / Yes / No / Don’t know
15. / If they live with a baby or small child, are they at risk in any way?
Details:
16. / Have they ever destroyed property or committed arson?
Details:
17. / Have they ever been threatening or violent towards others?
Details (eg peers, professionals):
18. / Have they ever been involved in any incidents with the police or courts where they received a warning, conviction etc?
Details:
19. / Are they known to the Youth Offending Service?
Details including which borough’s YOS:
Other agencies / professionals involved - currently
Agency / Contact Name / Tel. number / Address
Other agencies / professionals involved - previously
Agency / Contact Name / Tel. number / Address
Referral summary
Please summarise the reason for this referral:
What does the young person hope to gain from you making this referral?
Referring agency
Name of referrer:
Address:
Tel. Number:
Email address:
Name and contact details of worker working directly with young person (if different from above)
Signature of referrer
Date of referral
Office use only
Have risks been identified that should be taken into account when doing casework?
Yes No
If yes, what action(s) need to be taken to reduce the identified risks?
Have risks been identified that should be taken into account when doing activities?
Yes No
If yes, what action(s) need to be taken to reduce the identified risks?
Allocated counsellor(s):
From To
From To
From To

Please return this referral form to the address below by email, fax or post.

Faces in Focus, 102 Harper Road, London SE1 6AQ

Tel. 020 7403 2444 | Fax. 020 7207 2982 |