Referral form for Parent/Carer or Professional

Vale of Glamorgan School and Community Based Counselling Service – Referral form for Parent/Carer or Professional

I confirm the young person referred lives in the Vale of Glamorgan or they attend school in the Vale of Glamorgan, South Wales.

Is the young person aware of this referral?YesNo

Young Person Details

First name:

Last name:

Date of Birth:

First Line of address:

Postcode:

Gender:

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

Which school does the young person attend:

What school year are you currently in?:

Telephone number: please ensure you have consent from the young person to provide this number for them to be contacted on a weekday between 09:00-17.00

Email address:Please ensure you have consent from the young person to provide this email address for them to be contacted on a weekday between 09:00-17.00

What has been troubling the young person?

Person referring the young person details:

First name:

Last name:

Phone number:

Email address:

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).

Please be aware that the information you provide on this referral will be shared with the young person.