Referral form: Children and Young People

Information and consent

We will keep your information and the child’s information safe and confidential. We only use it to understand your needs and provide the right support. Please read our Sensory Services by Sight for Surrey Privacy Notice to find out how we collect, use and protect your personal information.

Please tick this box if you agree to us holding your information and the child’s personal information and data

Yes, I agree No, I don't agree

Professionals only

Does the family know and agree to this referral?

Yes No

Select an option

Please select a service

Habilitation Family Support Counselling

Sensory Services by Sight for Surrey has a counselling service available to both parents and young people living in Surrey who feel they would benefit from additional emotional support and the opportunity to explore issues that are causing them anxiety or concern. We have qualified counsellors registered with the British Association of Counsellors. They are able to provide a confidential, warm and accepting space to talk through issues that are causing distress. The charity’s Children & Young People’s Counselling service is able to offer an initial six sessions, there may be the opportunity to have further sessions depending on demand.

Information about the child

Child's name

Date of birth

Gender

House name or number

Street name

Post code

City

County

Information about the parent

Name

Contact email address

Contact phone number

Information about the person making the referral

Name

Job title

Organisation

Contact email address

Contact phone number

Reason for referral

Please be aware that the Counsellor needs 48 hours cancellation notice in order for sessions to be rearranged. In the event of a cancellation with less than 48 hour’s notice the charity will still be required to pay for the counsellor’s time. We will need to view this as a missed session to ensure that this limited resource is maximised. In the event of two missed sessions we will need to consider if this is the right time for you to make best use of this service. The charity will keep personal information safe and private. The details on this form will be shared with the Counsellor and recorded on the restricted part of the charity’s database. The Counsellor will share the general themes discussed for funding purposes, however details will not be shared unless the Counsellor becomes concerned about a safeguarding issue.

Information about the education setting

Name

Contact name

Contact email address

Contact phone number

All Habilitation training is commissioned by the Local Authority. We will be in touch as soon as possible with further details.