Make a counselling referral

Who are you making this referral for?*

Section Break

Please make your referral via the single point of access (SPA)

Based on the answers you have provided, your referral will need to be made via the Newcastle/Gateshead Single Point of Access (“SPA”). SPA can be contacted via email at NGSPAadmin@cntw.nhs.uk or by calling 0303 1231147.

Please respond to the following questions before completing the remainder of this form

Referrer name*

Referrer contact number*

Referrer email*

Young person's details

Personal Details

First Name*

Surname

Date of birth*

Preferred name / phonetic spelling of name

Gender*

Tell us your gender

Your pronoun*

Tell us your pronoun

Ethnicity*

Tell us your ethnicity

Does the person you're referring have a disability?*

Do you have a disability?*

Please tell us about the disability*

Please state disability

Sexuality

Please state sexuality

Are you looking for support as a victim of crime or hate?*

Is the person you're referring looking for support as a victim of crime or hate?*

What are your current living arrangements?*

What are the living arrangements of the person you're referring?*

Education, employment, or training status*

Which school / college / university do you attend?*

Which school / college / university do they attend?*

School / college/ university attended*

Is the school / college / university aware that this referral has been made?*

Contact details

Ward (if known)

Can we send letters to this address?*

Other ward

Phone number*

Can we get in touch via this phone number?*

Email address*

Can we get in touch via this email address?*

Registered GP surgery

GP surgery

Is the GP aware that this referral has been made?

Other agency involvement

Are any other agencies or professionals involved, or have previously been involved?*

Do you have a child protection plan?*

Is the person being referred currently subject to a child protection plan?*

Which agency / professional has been previously involved?

Are you currently on a waiting list for an assessment with any other agency?*

Is the person being referred currently on a waiting list for an assessment with any other agency?*

Other contact information

Emergency contact - name*

Emergency contact - phone number*

Relationship to you*

Relationship of emergency contact to the person being referred*

What is your preferred way for us to contact you?*

What is the preferred way for us to contact the person you're making this referral for?*

What is your first language?*

Do you need an interpreter?*

What is the first language of the person you are referring?*

Do they need an interpreter?*

Which language / dialect should the interpreter speak?

Do you have any additional access needs or allergies?

Does the person you are referring have any additional access needs or allergies?

How can we support with this?

Preference for support worker*

Support requested

Please state other support needed*

Tell us about why you're looking for support. What are your concerns / difficulties and how do these impact you?*

Reason for referral, what are the concerns/ difficulties and how do these impact the person being referred?*

When did these difficulties start?*

If you have experienced thoughts of suicide or self harm, when was the last time this happened?*

If the person you're referring has experienced thoughts of suicide or self harm, when was the last time this happened?*

If you know the specific support service you need, please select from the list below*

If you know the specific support service needed by the person you're referring, please choose from the list below*

Other support service. Please state*

Please give us more information about why you're referring to our children and young people's services*

How did you find out about Everyturn's children and young people’s services?*

Make a counselling referral