Inter Agency Referral

    Please complete this form by giving as much detail as possible.

    Your details:


    Young personsFamilyRelationshipIndividualCaring and SharingIndividual and Couple Therapy for DepressionSex TherapyPsychosexual support


    YesNo


    VoluntaryMandatory


    YesNo


    YesNo

    Please include the details for parents/carers in this section as they will be asked to attend an assessment if the referral is for young persons counselling and the young person is under 16.






















    YesNo

    YesNo


    Okay to say Relate callingOkay to emailOkay to write to addressPartner is not aware of contactUnder 16 – parents aware of contact


    MondayTuesdayWednesdayThursdayFridaySaturdaySundayMorningAfternoonEvening


    YesNo


    YesNo


























    YesNo

    We have a limited number of fully funded relationship and psychosexual therapy counselling
    sessions available.

    We have a limited number of fully funded Young People and Family counselling sessions
    available.

    We have a limited number of fully funded Caring and Sharing sessions available.

    People attending Relate services are asked to make a payment contribution towards the cost of their counselling or therapy, if fully funded sessions are not available.
















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