YMC COVID Relief Referral Form

As part of this project, we are aiming to address psychological and behavioral issues through 1:1 counselling for young people, and family counselling with their parent/guardian to create healthier family relationships.
Guidelines for completing this form:
 Please only refer the young person/family if they meet the following criteria:
o The individual must be aged under 18 at the time of referral.
o The child/young person SHOULD be exhibiting heightened anxiety, anger, or
mental health issues
o The child/young person must be living in Havering, Redbridge, Barking and
Dagenham or Waltham Forest
 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: *

Position:

Date of Referral:

Contact Address:

Phone: *

Email: *

Post Code:

Full Name: *

Nickname (if any)

Ethnicity:

Age:

Disability:

Risks and other important information:

Other Information if Necessary (Explain)

Guardian Name:

Guardian Email:

Guardian Address:

Home Number:

Mobile 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.