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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