Counselling Form

Required fields are marked with an asterisk*.

I am a…*Young person aged 7-25 years.Parent/guardian, completing on behalf of the young personProfessional supporting a young personParent/Guardian, completing on behalf of yourself

Full name of client*(if you are completing the form on someone else's behalf, please enter your own details in the relevant section below)

Date of birth*

Age*

Gender*
—Please choose an option—MaleFemaleTransgenderNon-binaryDo not wish to disclose

Address*

Postcode*

Your contact number*

Your email*

Best way to contact you?*
—Please choose an option—Phone callTextEmailDo not contact me, please go through my parent/carer

Name of parent/carer (if under 18 yrs)

Can we contact your parent/carer if necessary?
(You will always be told if we are going to make contact)
—Please choose an option—YesNo

Who do you live with?*

Education and/or employment*
At School6th Form/ collegeTraining/apprenticeshipEmployedFurther EducationNone of the above

Name of school (if applicable)

School/college year (if applicable)

Do you have any additional needs, or medical conditions?*
—Please choose an option—YesNo

Additional needs (If yes)

If being seen at the hub, will you require the use of the stair lift?*
—Please choose an option—YesNo

How do you think counselling can help you? *
Please provide as much information as possible

Are you receiving support from other agencies or people?*

How did you hear about Level Two Counselling?*

Where would you prefer to be seen?
This cannot be guaranteed but we will take this into consideration
—Please choose an option—At a school (Felixstowe schools only)At the hubEither

Availability Please select any times you CAN NOT attend. Please note that after school appointments are limited, so the more flexible you are with your availability, the quicker your counselling can be able to begin.

Is this referral for yourself?*
—Please choose an option—YesNo

If you are completing this form on someone else's behalf, please provide your details below.

I agree that I have completed this form or am aware that this form is being completed on my behalf. I understand this information will be kept safe and secure. I understand it will not be passed to other agencies or individuals outside of Level Two without asking or informing me first, unless required to do so by law (please see our policies on data protection on the website).