Page 1: Page 1

This form is for adults to refer a young person under 19 years of age for counselling. The young person must live in Newport to be eligible for an appointment.



6.6. Young Person's Gender Required
11.11. Has the young person agreed to counselling? Required
12.12. Reason for referral (tick up to 3 as appropriate) Required

Please select between 1 and 3 answers.

14.14. Are there any current or pending police investigations or court proceedings that relate to the child? Required

Police Investigation

Court proceedings

15.15. Any other services/professionals involved in child’s welfare (select as appropriate)
16.16. Does the young person have special educational needs (SEN) or a disability?

Dates need to be in the format 'DD/MM/YYYY', for example 27/03/1980.


This part of the survey uses a table of questions, 

17.17. Consider your observations of the child over the last two weeks and respond to the following statements below Required
Strongly Agree [3]Mostly Agree [2]Mostly Disagree [1]Strongly Disagree [0]Don't know [0]
The child appears often unhappy or regularly cries
The child appears withdrawn
The child gets angry or lashes out at people
The child seems anxious or panicky
The child is often tired or struggles to sleep
The child displays dangerous behaviour putting themselves or others at risk of harm
The child has difficulty with friendships
The child talks negatively about themselves
Overall the child’s difficulties have an impact on their school life
Overall the child’s difficulties have a negative impact on their home life
18.18. As the parent (or legal guardian), I have read and understood the Parent Consent Information & Privacy Notice and I agree to my child receiving counselling. Required

If you are NOT the Parent or Legal Guardian, please ensure that the Parental Consent Form is completed