REFERRAL FORM FOR YOUTH THERAPY

We can only offer counselling support to young people from North & West Belfast

Name Date of Birth

ADDRESS PostCode

NAME OF PARENT/GUARDIAN

Telephone

NATURE OF THE PROBLEM (Please tick all that apply)

Problems at school	Death/Bereavement	Sleeping difficulties
Problems with friends	Bullying	Relationship difficulties
Family illness	Drug/alcohol misuse	Self harm
Domestic violence	Physical/emotional/sexual abuse	Depression/Anxiety
Difficulties with parents/children	Suicidal thoughts/behaviours	Problems due to the “Troubles”
Family separation/divorce	Sexual assault/rape	Victim of crime

Other

OTHER INFORMATION (medical history, family history, further details on current situation)

ARE GROUND FLOOR FACILITIES REQUIRED? YES NO

HOW DID YOU HEAR OF THIS SERVICE?

REFERRER DETAILS:

Are you asking for help for yourself

NAME/POSITION TEL

ADDRESS

Reset

SEND FORM

If you are having problems submitting this form please contact our office number 028 90 391630 and we will take youe referral over the phone.