First name
Family name
Date of birth
Address
Postcode
Gender
Council area ---KirkleesLeedsBradfordWakefieldCalderdale
Current education ---SchoolCollegeUniversityNone
School Attending
Is the young person receiving any support from any other ‘professionals’? NoYes
If yes, who?
Is the young person on a waiting list for any other services? (e.g. CAMHS, counselling) NoYes
Is the young person aware of the referral to ESCAYP? NoYes
Does the young person have any special needs to be taken into account before counselling is offered? (e.g. interpreter, access / mobility) NoYes
If yes, please give details
Please select all that apply SuicideSelf harmSelf neglectViolenceVerbal aggressionPhysical aggressionVulnerability
Other risk details (please state)
Name
Contact number
Email address
Referring agency / organisation
Who advised this referral?
Relationship to young person ---ParentRelativeSelf-ReferralSupport WorkerOther
Can we leave a message? NoYes
Relationship to young person ---MotherFatherGrandparentFosterAdoptive Parent
Does the child / young person have any health issues / disabilities that we need to know about? NoYes
If yes please briefly state what they are
Is this the first referral to ESCAYP? NoYes
Are there any present / previous family members who have been referred to ESCAYP? NoYes
Is there an ongoing or pending court case? NoYes
If yes, what is the name of the police liaison office?
And their contact number
All counselling is carried out on a 1 to 1 basis. Any information given by the referrer may be shared with the young person. All information from the young person will be confidential, but and will be treated within the guidelines of the Child Protection and Safeguarding Boards and the British Association for Counselling and Psychotherapy (BACP) Please Note: At Escayp, we store securely information (data) on paper and electronically. This data consists of our contacts with you; from your referral form and information from Counsellors, Teachers, Parents and Carers. Your privacy is important to us, so we will always keep your details secure. This data is stored securely on our server (protected by passwords) and in locked filing cabinets – access is restricted to ESCAYP staff and to our Researcher. The data is used for research purposes and it is always kept anonymously. We use it to make improvements to our service and it also helps us with bids to get more funding. We keep this information until the young person reaches the age of 21 years (or seven years from the date we last made contact depending on age at referral). After this time we will delete all electronic data and destroy all paper based copies we hold.By completing this form you are giving your consent for your data to be held by ESCAYP and for the above named person to receive Counselling or Therapeutic Play from ESCAYP By completing this form you are giving consent for your data to be shared where appropriate with our researcher. (This will not include session content / personal details.)
If you are aged 16 years or over please tick this box to confirm your agreement for Escayp to hold your details as explained and process this referral. Or if you (i) or parent/guardian please tick this box to confirm your agreement for Escayp to hold your details as explained and process this referral.
If completed on behalf of parent / carer / young person by an organisation / school please tick the box to authorise young person's / parent / carer consent as set out above.
