Self Referrals for Young Persons Counselling

Vale of Glamorgan School and Community Based Counselling Service – Self referral form for Young person

I confirm I either live in the Vale of Glamorgan or I attend school in the Vale of Glamorgan, South Wales.

First name:

Last name:

Date of Birth:

Gender:

How would you like to receive counselling? Online (e.g. Microsoft Teams, Zoom or WhatsApp)Face to face (in the community) – choose this option if you want to be seen outside of school or if you do not attend school or if you attend a primary schoolFace to face (in your secondary school)

Which school do you attend:

What school year are you currently in?:

Your telephone number:

Your email address:

Is your parent/carer aware of this referral?:YesNo

Do we have your consent to contact you outside of school?:YesNo

What has been troubling you?

The data contained in this form will be used by Barnardo’s to identify and provide the most appropriate service. The data will be stored securely and deleted in accordance to Barnardo’s privacy policy.

Registered office: Tanners Lane, Barkingside IG6 1QG. VAT number 507477337. Barnardo's is a charity (216250 / SC037605) and a company limited by guarantee. (61625 England - see the governing document).