Online Referrals This form is for all self-referrals and referrals. Counselling is free for 11-25 year olds. We also provide counselling for adults aged 26 years+ (often parents find it helpful), we charge £20 per session (50 mins) for adults aged 26 years and above. Please complete this form whichever age bracket you fall into. Thank you. Client Ref No.:Allocated to:Name of counsellorDate of first session:Date of last session:DETAILS OF PERSON SEEKING COUNSELLINGName* First Last Date of birth* Date Format: MM slash DD slash YYYY Please tell us your age*Gender*MaleFemaleNon BinaryAgenderGender FluidQuestioningHome Postcode*Current School/CollegeGP surgery name*How did you hear about No5?*GPSchoolSocial WorkerBrighter Futures for ChildrenFriendFamilyNo5 WebsiteSocial MediaSearch EnginePlease tell us your ethnicity (for reporting purposes)*WhiteMixed / multiple ethnicAsian or Asian BritishBlack / African / Caribbean / Black BritishArabWhite*EnglishWelshScottishN. IrishBritishIrishGypsy or Irish TravellerMixed / multiple ethnic*White / Black CaribbeanWhite / Black AfricanWhite / AsianAsian or Asian British*IndianPakistaniBangladeshiChineseBlack / African / Caribbean / Black British*CaribbeanAfricanREFERRER DETAILSWho is making this referral?*I am self-referringReferred by someone elsePlease provide your/referrer contact details, these will be our initial point of contact.Referrer name*If you are self-referring please re-enter your name. First Last Referrer mobile*Referrer email* Referral organisation/relationship (if applicable)e.g. Mother/Father/Agency nameABOUT YOUR COUNSELLINGHow would you like to receive counselling? Please select as many as you can so to provide the maximum counselling provision options. Zoom Face to face Phone Have you been seen by CAMHS?YesNoAre you on CAMHS waiting list?YesNoDo you have a counsellor preference?Male counsellorFemale CounsellorDon’t mindPlease briefly explain why you are seeking counselling with No5*Bullet points are fine.Monday - 3pm; 4pm; 5pm; 6pm; 7pm; 8pmTuesday - 10am; 11am; 12pm; 3pm; 4pm; 5pm; 6pm; 7pm; 8pmWednesday - 3pm; 4pm; 5pm; 6pm; 7pm; 8pmThursday - 10am; 11am; 12pm; 3pm; 4pm; 5pm; 6pm; 7pm; 8pmFriday - 3pm; 4pm; 5pm; 6pm; 7pm; 8pmPlease enter the date & details of each contact and your initials. Client ref no.EmailThis field is for validation purposes and should be left unchanged.
