Need urgent help right now? Support is available

Refer a young person

For a child or young person. We'll contact you, their parent or carer, to arrange things - so please make sure your own details are right.

Looking for something else? for myself, for us as a couple, for our family, creative therapy for a child.

Your details are encrypted in your browser before they are sent, and can only be read by our team. Fields marked *are required. If you're in immediate distress, please contact the Samaritans on 116 123 (free, 24/7) or call 999.

About the young person

Their first name *

Their last name *

Title (optional)

Date of birth (optional)

About you (parent or carer)

This is how we'll get in touch. We don't contact a young person directly without arranging it with you first.

Your name *

Your relationship to them *

Your phone *

Your email (optional)

Your address (optional, if different)

Your postcode (optional)

Is someone else making this referral?

Only if a school, GP, support worker or someone else is filling this in on their behalf. Leave it empty if you're referring yourself.

Their name (optional)

Organisation (optional)

Their phone (optional)

Their email (optional)

Their own contact details

Only if the young person has their own phone or email and is happy for us to use it. Otherwise leave these blank - we'll contact you.

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)

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 slots are limited, so anything you can tick helps)

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. *

	Morning	Afternoon	Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday