12-20 years old referral form

Service user details

Client name

Name of parent/guardian

Email of parent/guardian

Phone number of parent/guardian

Legal guardian consent

I give consent

If under 18, NB if the client is 16/17 they may give consent as long as they have mental capacity inline with Fraser guidelines and Gillick competence.

Date of birth

Landline phone number

Mobile phone number

Address

Street Address Address Line 2 City County Post code

Email

Education provider school/college/university

How would you like to be contacted?

Landline phone

Mobile phone

Post

Email

Is it safe to: (tick as necessary)

Leave a message on the telephone numbers you have given?

Identify ourselves to your carers/partner etc on the phone?

Leave you messages via email?

Mark envelopes ‘Private and Confidential’ if we write to you?

First language/languages spoken

Language requirements

Interpreter required

Sign language interpreter required

GP and medical history

GP Name and Surgery

Address

Street Address Address Line 2 City County Post code

GP Phone number

Medical history (optional)

Medication

Allergies

Dietary needs

Disabilities (neurodiverse/ Physical etc)

Referrers information

If you are referring yourself please skip this section

Referrer’s name

Referrer’s organisation

Referrer’s email

Referrer’s phone number

Reason for referral

Emergency Contact

Who should we contact if an emergency happens while you are with us?

Please remember that you may prefer this person to know you are having counselling with us, in case we have to call them in an emergency

Emergency contact name

Emergency contact address

Street Address Address Line 2 City County Post Code

Emergency contact phone number

Emergency contacts relationship to you

Privacy Statement

We are collecting your personal details and GP details to use during our work together. In case of crime or harm to yourself or others, I would need to contact the appropriate authorities. My need for knowing your medication or medical conditions, is to be aware of how these affect you during our work together.

Confidentiality & Exceptions

Under certain other circumstances it may be necessary for me to breach confidentiality by talking to someone. This may happen if;

You give us your consent for this confidence to be broken.
compelled to break that confidence by a court of law, child protection or the terrorism act 1987.
Harming yourself or others. In such circumstances we would always try and talk to you first.
A referring agency require a report. However, we would devise this together.
We want to reassure you that we will not disclose any information about you to any other agencies or third parties without your knowledge and consent apart from in exceptional circumstances.

Consent

To allow Alumah using photos or short videos, which may include the individual in local publications, our social media and website. Please tick the box. N.B most photos will be of projects produced.

For the young person taking part in indicated sessions.

Emergency first aid considered necessary N.B. the medical profession takes the view that parental consent to medical treatment cannot be delegated. Medical forms have no legal status, and a doctor has the right to insist on parental consent before treating a child. We have found, however, that medical staff find this type of general consent helpful.

Are you happy for us to keep and store your information on our database? (This is NOT shared with anyone else, unless discussed with you). We need a record of your information to make sure we are working safely and ethically as well as being able to see that you are getting the support you need. We also need to be able to add you to our waiting lists if necessary and without consent to use our database we will be unable to do this.

Are you happy for us to use any feedback you give us?