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Refer a child for creative therapy

Creative and expressive therapy for children - working through play, art and story rather than only talking. Often referred by a school, but families can refer directly too.

Looking for something else? for myself, for a young person, for us as a couple, for our family.

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About the child

Their first name *

Their last name *

Title (optional)

Date of birth (optional)

About the parent or guardian

This is how we'll get in touch about the child.

Your name *

Your relationship to them *

Your phone *

Your email (optional)

Your address (optional, if different)

Your postcode (optional)

Who is making this referral?

Often a school or another service. Leave blank if you're the child's parent or carer referring them yourself.

Their name (optional)

Organisation (optional)

Their phone (optional)

Their email (optional)

Their role (optional)

Their own contact details

Only if the child has their own contact details. Otherwise leave blank - we'll contact their parent or guardian.

Email address *

Mobile number (optional)

Home phone (optional)

Postcode (optional)

Address (optional)

It's OK to leave a voicemail or message if we call.

Your GP

Optional - it can help us support you, but you don't have to share it.

GP name or practice (optional)

GP phone (optional)

GP address (optional)

GP postcode (optional)

What brings you here?

In your own words * Share as much or as little as you're comfortable with.

A little about your circumstances

All optional. Only tick what applies - it helps us support you well and match you with the right person.

I have a disability or access needs

I'm currently experiencing mental-health difficulties

I've had a recent hospital admission

I'm taking medication

There are current legal proceedings involving me

I've had counselling or therapy before

Getting to us, and being comfortable when you do

All optional. It helps us pick the right room and make the appointment workable.

I can manage stairsI'm deaf or hard of hearingI'm blind or have a sight impairmentI have another access need

Anything that would help us (optional)

Language (optional)

Allergies (optional)

Their school

Optional, but it helps us work around the school day.

School name (optional)

School phone (optional)

School address (optional)

An after-school appointment would suit us best

Earliest you could reach us after school (optional)

A bit more about them

These help the therapist prepare. All optional.

Family situation (optional)

Any learning difficulties (optional)

Other services already involved (optional)

An educational psychologist is involvedThe child knows about this referral and is happy to come

What do you think is behind it? (optional)

What do you hope will change? (optional - up to four things)

You may use anonymised information from our sessions for research. (Entirely optional - it makes no difference to the support we receive.)

Your consent as their parent or carer

I give consent for them to attend counselling sessions.

Your name, as consent (optional)

Your preferences

All optional - we'll do our best to match them.

How would you like to meet? (optional)

Counsellor preference (optional)

When are you usually free? (optional - after-school appointments are limited)

Equal-opportunities monitoring

Entirely optional and never used to make decisions - it only helps us check we're reaching everyone fairly. Skip any you'd rather not answer.

Gender (optional)

Sexual orientation (optional)

Ethnicity (optional)

If you chose another ethnic group, please describe it (optional)

I consent, as their parent or carer, to Empathy Northwest CIC using the information on this form - including anything about their health or the reasons for seeking support - to contact me and arrange therapeutic support for them. I understand it is kept confidential, that I can withdraw my consent at any time, and that it is handled as set out in the Privacy Policy. *I have parental responsibility for them, or I am authorised to make this referral on their behalf. *

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