Referral Form

Fill out this form to get counselling

1Introduction

2About You

3Counselling

4Contact Info

5More Info

7Review

This form is for all self-referrals and referrals. Counselling is free for 11-25 year olds. Please complete this form whichever age bracket you fall into. Thank you.
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Client Ref No.:
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Allocated to:
Name of counsellor
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Date of first session:
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Date of last session:
If you have any queries about how your data will be held, please see our privacy policy
Who is making this referral?(Required)
- I am referring myself
- I am a parent or caregiver referring a young person
- I am a professional referring a young person
Has the young person consented to this referral?(Required)
- Yes
- No

2
About You
About the young person seeking counselling
Title
Name(Required)
First Name Surname
Would you like to share your chosen pronouns with us?
Would you like to share their chosen pronouns with us?
Would you like to share your chosen pronouns with us?
- Yes
- No
Your chosen pronouns
Their chosen pronouns
Your chosen pronouns
- He/him
- She/her
- They/them
- She/they
- He/they
- They/she
- They/he
Date of Birth(Required)
Address
Address Line 1 Address Line 2 Town/City
Postcode(Required)

Please include spaces in your postcode for example: RG1 2AB
Would you like to receive resources and information to this address?
Would they like to receive resources and information to this address?
Would you like to receive resources and information to this address?(Required)
- Yes
- No
If no, would they like to receive resources and information by email?
If no, would they like to receive resources and information by email?
If no, would you like to receive resources and information by email?(Required)
- Yes
- No
Email address to receive resources and information

3
About Your Counselling
About the young person counselling
First referral to No5?
- Yes
- No
- Unknown
How did you hear about us?
How did they hear about us?
How did you hear about us?(Required)
- GP
- School
- Friend
- Family
- Google search
- Social media
- Social worker
- Youth worker
- Family worker
Please briefly explain why you are seeking counselling
Please briefly explain why you are seeking counselling for them
Please briefly explain why you are seeking counselling(Required)
Bullet points are fine.
Please select any and all of these that apply to why you are seeking counselling
- Abuse
- Addiction
- Anger
- Anxiety
- Bereavement
- Bullying
- Depression
- Family Issues or Breakdown
- Financial issues and worries
- Low self-esteem
- Sleep
- Disordered eating
- Phobias
- OCD
- ADHD
- Autism
- Other mental health issues
- Physical health
- Special Educational Needs
- Disability
- Relationships (family, partner) inc religious or cultural clashes
- Relationships (non-family), social, emotional skills, loneliness, work
- Self-harm
- Sexuality
- Gender-related issues
- School-related issues
- Suicidal Thoughts/Suicide
- Other
If other please specify
You can access support at No5 in different ways, please select all options that you would be happy with:
You can access support at No5 in different ways, please select all options that they would be happy with:
You can access support at No5 in different ways, please select all options that you would be happy with:
- In-person at No5’s building (central Reading)
- Remote video (Zoom)
- Telephone
In-person counselling availability

Counselling takes place Monday-Friday
For 11-17 year olds, in-person sessions start at 4pm, 5pm and 6pm.
For 18-25 year olds, in-person sessions starts at 7pm and 8pm.
Remote counselling availability

Remote counselling sessions take place Monday-Friday, starting at 4, 5, 6, 7 and 8pm
Telephone counselling availability

Telephone sessions take place Monday-Friday, starting at 4, 5, 6, 7 and 8pm
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In-person counselling availability
Counselling takes place Monday-Friday
For 11-17 year olds, in-person sessions start at 4pm, 5pm and 6pm.
For 18-25 year olds, in-person sessions starts at 7pm and 8pm.
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Remote counselling availability
Remote counselling sessions take place Monday-Friday, starting at 4, 5, 6, 7 and 8pm
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Telephone counselling availability
Telephone sessions take place Monday-Friday, starting at 4, 5, 6, 7 and 8pm
Are there any days and times that you are not available?
Are there any days and times that they are not available?
Are there any days and times that you are not available?
Are you available between 9am and 1pm on a Wednesday?
Are they available between 9am and 1pm on a Wednesday?
Are you available between 9am and 1pm on a Wednesday?
- Yes
- No
Do you have a preference around the gender of your counsellor? We will do our best to accommodate this however you may wait longer for support. Please state:
Would they have a preference around the gender of their counsellor? We will do our best to accommodate this however they may wait longer for support. Please state:
Do you have a preference around the gender of your counsellor? We will do our best to accommodate this however you may wait longer for support. Please state:
- Female
- Male
- I don’t mind
Access Needs
Accessibility Communication Support
- Does use hearing aid
- Does lipread
Select all that apply
Accessibility Support
- Uses a wheelchair
- Uses a walking aid
- Has a visual impairment
- Uses a guide dog
- Uses a visual aid
Select all that apply

4
How can we get in touch with you?
How can we get in touch with the young person?
Primary contact method
- Call
- Text
- Email
Secondary contact method
- Call
- Text
- Email
Telephone Number(Required)
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Referrer Landline
Can we call this number?
- Yes
- No
Can we leave a voicemail on this number?
- Yes
- No
Can we send a text to this number?
- Yes
- No
Email Address(Required)
Can we send an email to this address about your counselling?
Can we send an email to this address about their counselling?
Can we send an email to this address about your counselling?
- Yes
- No
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Client Landline
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Monday - 3pm; 4pm; 5pm; 6pm; 7pm; 8pm
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Tuesday - 10am; 11am; 12pm; 3pm; 4pm; 5pm; 6pm; 7pm; 8pm
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Wednesday - 3pm; 4pm; 5pm; 6pm; 7pm; 8pm
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Thursday - 10am; 11am; 12pm; 3pm; 4pm; 5pm; 6pm; 7pm; 8pm
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Friday - 3pm; 4pm; 5pm; 6pm; 7pm; 8pm
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Please enter the date & details of each contact and your initials. Client ref no.

5
More information about you
More information about the young person
GP Details
Name of GP Surgery(Required)
GP surgery name other(Required)
I am currently
They are currently
I am currently
- At school
- At college
- At University
- In training
- Employed
- Unemployed
Name of school/college/university
Asylum seeker
Please tick here if you are an asylum seeker.
My Identity
Young person identity
I identify my ethnicity as:
They identify their ethnicity as
I identify my ethnicity as:(Required)
Ethnicity Other(Required)
I identify my gender as:
They identify their gender as:
I identify my gender as:(Required)
Gender Other(Required)
I identify my sexuality as:
They identify my sexuality as:
I identify my sexuality as:
Sexuality Other
I identify as having a disability:
They identify as having a disability:
I identify as having a disability:
- Yes
- No
- Prefer not to say
Disability
Have you had counselling before?
Have they had counselling before?
Have you had counselling before?
- Yes
- No
- Prefer not to say
This can be at No5 or elsewhere
Are you on any medication that it is important for us to be aware of?
Are they on any medication that it is important for us to be aware of?
Are you on any medication that it is important for us to be aware of?
- Yes
- No
- Prefer not to say
Medications
Do you have any medical conditions that it is important for us to be aware of?
Do they have any medical conditions that it is important for us to be aware of?
Do you have any medical conditions that it is important for us to be aware of?
- Yes
- No
- Prefer not to say
Medical conditions
Have you been seen/supported by CAMHS?
Have they been seen/supported by CAMHS?
Have you been seen/supported by CAMHS?
- Yes
- No
- Prefer not to say
Are you on the CAMHS waiting list?
Are they on the CAMHS waiting list?
Are you on the CAMHS waiting list?
- Yes
- No
- Prefer not to say
Are you a young carer?
Are they a young carer?
Are you a young carer?
- Yes
- No
- Prefer not to say

5
Parent/Carer referring a Young Person - About You
Professional referring a Young Person - About You
Title
For Professional(Required)
First Name Surname
Organisation(Required)
Would you like to share your chosen pronouns with us?
- Yes
- No
Your chosen pronouns
- He/him
- She/her
- They/them
- She/they
- He/they
- They/she
- They/he
Address
Address Line 1 Address Line 2 Town/City Postcode
Relationship to young person(Required)
Other Relationship
How can we get in touch with you?
Primary contact method
- Call
- Text
- Email
Secondary contact method
- Call
- Text
- Email
Telephone Number(Required)
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Telephone Number New
Can we call this number?
- Yes
- No
Can we leave a voicemail on this number?
- Yes
- No
Can we send a text to this number?
- Yes
- No
Email address
Can we send an email to this address about counselling?
- Yes
- No
Can we send emails to this address containing support information and advice written by young people?
- Yes
- No
Are you the main contact we should speak to about this young person’s counselling?
- Yes
- No
Who should we contact about this young person’s counselling:
Name(Required)
First Name Surname
Relationship to young person(Required)
Other Relationship
Email address
Phone Number(Required)

6
Review your referral
{all_fields}
Data consent(Required)
- I consent to No5’s Data Protection Policy and Confidentiality Policy

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Need urgent help

Young Minds: Free 24/7 crisis messenger – Text YM to 85258

Childline: One-to-one online chat with a counsellor, visit the Childline website

The Mix (for under 25s): 24/7 crisis messenger: Text THEMIX to 85258

Papyrus (Suicidal thoughts): Call 0800 068 4141, text 07860039967 or visit their website to see loads of resources and things to try.

Samaritans: 24/7 phone line (116 123) or email Jo.

CALM – Campaign Against Living Miserably: Helpline open 5pm – midnight – 0800585858. Webchat available 5pm – midnight.

Shout: Free (on all major mobile networks), 24/7 crisis text service – Text SHOUT to 85258

If you are in an emergency and there is risk to life (your own or another person’s) call 999

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Referral Form

If you have any queries about how your data will be held, please see our privacy policy

About You

About the young person seeking counselling

About Your Counselling

About the young person counselling

Access Needs

How can we get in touch with you?

How can we get in touch with the young person?

More information about you

More information about the young person

My Identity

Young person identity

Parent/Carer referring a Young Person - About You

Professional referring a Young Person - About You

How can we get in touch with you?

Who should we contact about this young person’s counselling:

Review your referral