Teen Counselling Referral Form

REFERRAL FORM

Name of Referred Person(Required)

First Last

Hidden

Name(Required)

Date of Birth(Required)

Gender

Please give more details:

Address(Required)

Parental Information

Parent 1 Please fill in relevant details.

Name

First Last

Phone

Address

Are you a legal guardian?

Please provide details of the Legal Guardian

Parent 2 Please fill in relevant details.

Name

First Last

Phone

Address

Are you a legal guardian?

Please provide details of the Legal Guardian

Are both legal guardians consenting to the young person attending counselling:

If 'No', please state reason

Other Information

Is there a current child protection case:

If 'Yes', please give details of social worker:

Social Worker Name

First Last

Phone

Address

Is the young person in foster/residential care?

Please state if the young person is in voluntary or involuntary care?

Please enter the contact details of foster/ residential care:

Name

Phone

Address

Referrer details:

As someone referring someone else, please provide your details

Referrer Name

First Last

Referrer Address

Referrer Phone

Referrer Email

If you have selected 'Other', please provide details:

Is the young person currently attending any other services:

If 'Yes' please state which services.

School

School Year

Please provide GP contact details:

GP Name

Phone

GP Address

Other Info:

If you are a Social Worker, please fill in your details below:

Social Worker

SW Area

SW Team

Name

Telephone

Social Worker Team Lead

SW Area

SW Team

Name

Telephone

Principal Social Worker

SW Area

SW Team

Name

Telephone

Please state the reasons for which you are referring the young person into counselling.

Is the young person aware of this referral?

If no, please state reason:

Please indicate which centre is most convenient for you below

Has the young person any special requirements such as wheelchair access/ interpreter needed?

If 'Yes' please state the requirements needed:

Please click the button to open up the Consent & Information sheet. This allows you to read and understand this before we meet.

Click here for C&I Sheet

Please email teencounselling@crosscare.ie If you have any special requirements or for further info. Please get in touch with 01 557 4705

Please be advised that waiting lists vary across centres, However, we will do our best to see you in a timely manner.

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Child Protection Statement

We provide a confidential service. However, if you give information which suggests that a child or adolescent is at risk of abuse or neglect, or that they have been hurt in the past we will contact TUSLA with this information. Talk to us if you are not sure if this refers to you

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Teen Counselling Referral Form

REFERRAL FORM

Parental Information

Other Information

Child Protection Statement

Get in touch with Crosscare today

Corporate Support

Donate Now

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