Counselling Referral Form

Young People Counselling Referral form

Confidential.
This form should take about 5 - 10 minutes to complete.

Your initial assessment

It’s important to have the right therapist who understands you. Assessments are done by our lead counsellors, who have a lot of knowledge, and know our team well. They’ll guide you through the process of finding the right therapy for you, and the best counsellor to talk to.
How much does it cost?

The initial assessment is £30 and £60 for ongoing appointments.

Data protection

Read more about how we use and protect your data here
Client / Guardian gives consent for Platfform Wellbeing counselling service to hold and process any personal data which may be needed for the counselling process*

Yes

Referral form

Please answer this section if you are completing this form on behalf of a young person
Referral submitted by: Full name*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Referral form

Contact information
Young Person Telephone Number*
Young Person Email*
Send SMS appointment reminders to:*

Parent / GuardianYoung person / ClientNo SMSreminder
Send email appointment reminders to:*

Parent / GuardianYoung person / ClientNo email reminder
Address line 1*
Address line 2
City*
County
Postcode*

Referral form

About you
What would you like to work on through counselling?*
Please provide information on your situation

Referral form

How did you hear about us?
How did you hear about us?*

Google / Online searchSocial mediaBing/MicrosoftWord of mouthCounselling DirectoryPsychology TodayOtherFlyer
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Young People Counselling Referral form