Online Referrals This form is for all self-referrals and referrals. Counselling is free for 11-25 year olds. HiddenClient Ref No.: HiddenAllocated to:Name of counsellor HiddenDate of first session: HiddenDate of last session: DETAILS OF PERSON SEEKING COUNSELLINGName* First Last Date of birth* DD slash MM slash YYYY Please tell us your age* Gender* Male Female Non Binary Agender Gender Fluid Questioning Home Postcode* GP surgery name* Current School/College/University How did you hear about No5?* GP School/College Reading University Social Worker Brighter Futures for Children CAMHS Talking Therapies Friend/Family No5 Website Social Media Search Engine Please tell us your ethnicity (for reporting purposes)* White Mixed / multiple ethnic Asian or Asian British Black / African / Caribbean / Black British Arab White* English Welsh Scottish N. Irish British Irish Gypsy or Irish Traveller Mixed / multiple ethnic* White / Black Caribbean White / Black African White / Asian Asian or Asian British* Indian Pakistani Bangladeshi Chinese Black / African / Caribbean / Black British* Caribbean African REFERRER DETAILSWho is making this referral?* I am self-referring Referred by someone else Please 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* Enter Email Confirm Email Referral organisation/relationship (if applicable)e.g. Mother/Father/Agency name ABOUT YOUR COUNSELLINGHow would you like to receive counselling? Please select as many as you can so to provide the maximum counselling provision options. Zoom (from your home) Zoom (from No5 office) Face to face Phone Unsure (I'd like to discuss) Have you been seen by CAMHS? Yes No Are you on CAMHS waiting list? Yes No Do you have a counsellor preference? Male counsellor Female Counsellor Don’t mind Please briefly explain why you are seeking counselling with No5*Bullet points are fine.How would you like to receive activities and materials from our Young Ambassadors?*We have wellbeing materials we can post to you free of charge. Alternatively, we can send a digital version via email. Please indicate your preference below. Post Email Not interested Young Person's AddressIf you would like to receive mental health materials and activities in the post please complete your address below. 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HiddenMonday - 3pm; 4pm; 5pm; 6pm; 7pm; 8pm HiddenTuesday - 10am; 11am; 12pm; 3pm; 4pm; 5pm; 6pm; 7pm; 8pm HiddenWednesday - 3pm; 4pm; 5pm; 6pm; 7pm; 8pm HiddenThursday - 10am; 11am; 12pm; 3pm; 4pm; 5pm; 6pm; 7pm; 8pm HiddenFriday - 3pm; 4pm; 5pm; 6pm; 7pm; 8pm HiddenPlease enter the date & details of each contact and your initials. Client ref no.PhoneThis field is for validation purposes and should be left unchanged.
