Tele-play Therapy Referral Form

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1.1. Referral date Required

(dd/mm/yyyy)

2.2. Your name Required

a.2.a. Your relationship to child e.g. parent, teacher, guardian Required

b.2.b. Your email address Optional

c.2.c. Your telephone number Optional

3.3. Young Person's Full Name Required

4.4. Young Person's Preferred Name Optional

5.5. Young Person's Date of Birth

(dd/mm/yyyy)

6.6. Young Person's Gender Required

Male

Female

7.7. Young Person's Address Required

8.8. Young Person's GP surgery Required

9.9. School Required

10.10. Year group Required

11.11. Has the young person agreed to counselling? Required

Yes

No

12.12. Reason for referral (tick up to 3 as appropriate) Required

Please select between 1 and 3 answers.

Abuse (incl sexual)

Academic

Anger

Anxiety

Behaviour related

Bereavement

Bullying

Caring responsibilities

Cyber-safety (incl. cyber cullying and sexting)

Depression

Domestic Abuse

Eating disorders

Family

Financial concerns / poverty

Illness

Offending

Relationship with boyfriend/girlfriend

Relationships with teachers

Relationships other than family or teachers

Self-harm

Self-worth

Sexual (inc. orientation)

Stress

Substance Misuse

Suicide

Transgender issues

Other

13.13. Please explain the reasons for the referral including any support the child is receiving Required

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

Yes

No - go to Q16

a.14.a. If Yes, please provide further details: Optional

Police Investigation

b.14.b. Investigating Officer Name Optional

i.14.b.i. Contact Details Optional

Court proceedings

c.14.c. Name of ISVA and/or Social Worker Optional

i.14.c.i. Contact details Optional

15.15. Any other services/professionals involved in child’s welfare (select as appropriate)

EP Service

Behaviour Support Service

Education Support Worker

Child Protection Register

Education Welfare Service

Advisory Teacher

(LAC) Social Services

Health Professionals

16.16. Does the young person have special educational needs (SEN) or a disability?

Yes

No

Don't know

a.16.a. If yes, please select from drop down list Optional

Please select Cognitive/Learning Behaviour/Emotional/Social Development Communication/Interaction Sensory Physical

b.16.b. If yes, please provide further details Optional

c.16.c. Date of Special Educational Needs Statement Optional

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

(dd/mm/yyyy)

This part of the survey uses a table of questions, view as separate questions instead?

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

Yes

No

I am not the parent or guardian

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