Change Through Choice Referral Form – You and Me Counselling

YMC #ChangeThroughChoice (Young Londoners) Referral Form

As part of this project, we are aiming to address psychological and mental health issues through 1:1 counselling, create healthier family relationships through parental support, motivate young people through peer mentoring, and support practical rehabilitation.
Guidelines for completing this form:
 Please only refer the young person/family if they meet the following criteria:
o The child/young person must be between the ages of 10 and 21 as of the 7th
January 2018
o The child/young person SHOULD be either at risk of exclusion or
involvement in criminal activity, or have been involved in criminal activity.
o In addition to the above, the child/young person could be suffering from
mental health issues.
o The child/young person must be living in Havering.
 If under 16, please inform the young person and their parent/carer of the referral
before referring.
Please contact us if there is anything you are unsure of. Please note that due to the limited number of places available in this project, a referral does not guarantee we will be able to offer the young person/family a place. We will review the information provided and inform you of our decision accordingly.

Referring School / Agency / Self: *

Name of Referrer: *

Position:

Date of Referral:

Contact Address:

Phone: *

Email: *

Post Code:

Full Name: *

Nickname (if any)

Ethnicity:

Age:

Disability:

Risks and other important information:

Additional Info if Necessary (Please Explain)

Name: *

Email: *

Address:

Home Number:

Phone Number: *

Work Phone:

Using the criteria above as a guide, could you briefly explain the concerns you have for this child/young person? How long has this individual demonstrated these behaviours or concerns?

I Agree to the Statement Below *

I have read and understood the information given to me regarding the services You
and Me Counselling will be providing me. I understand that if I have further
enquiries, I can discuss them with the staff.
 I understand that while I / the young person named above is working with You and
Me Counselling, I/they/we will be subject to the service’s code and conduct of
behaviour and will be required to conform with the instructions and guidance of the service.