Home / Young People’s Counselling Referral Form (17-21)

Self-Referral Form for ages 17-21

If you are aged 17-21, please use this form to self-refer to our Counselling Service for Young People.

"*" indicates required fields

Is it OK to leave a message from Buckinghamshire Mind on this number?*
Can we have permission to contact you?*
Are you at risk of harm to yourself or to others?*
Do you have any special educational needs including ASD/ADHD/ADD?*
Please read the Terms set out below this form.
What is your preferred time for an appointment?*
We currently do not offer any appointments for Young People’s Counselling after 5pm. Please note that we can’t guarantee that appointments at your preferred time, but we will try our best to accommodate your preference.
Would you prefer online or face-to-face sessions?*
Online counselling offers benefits and challenges and is not suitable for some people. This will be decided between the counsellor and client during the Initial Assessment.
If face-to-face, which is your preferred location for sessions?


Should the referral be accepted (following the Initial Assessment), I understand that the counselling sessions will be as follows:
  • Sessions will last up to 50 minutes and will be weekly, taking place on the same day and time each week (unless it is agreed between counsellor and client otherwise).
  • Sessions will take place in a private and confidential space with only the counsellor and client. This applies to both face-to-face sessions and online.
  • After the Initial Assessment, if deemed the right support, clients will be offered up to 10 sessions.

Counsellor Information

  • Our counselling team comprises employees and volunteers who are either fully qualified or are undertaking a placement in the final year/s of a counselling diploma or equivalent.
  • Buckinghamshire Mind will not provide a personal contact number for counsellors. If you need to pass on messages or inform your counsellor of a cancellation outside of your session time, please call the office on 01494 463364.


  • We require 24 hours’ notice cancellation. Please be aware that our counsellors are there for you at the allocated time and unless notice is given, they cannot offer this slot to another young person who may need our support.
  • For any late or last-minute cancellations, the missed session will be counted as one of your allocated sessions.
  • If you cancel twice with or without notice, your counsellor will discuss with you if counselling is still appropriate.
  • If you miss 2 consecutive sessions without any prior notice or contact, we will assume you no longer require counselling and will not be returning to counselling. If this happens and you find yourself needing future support, you can re-enter the service and go on our waiting list.
  • Your counsellor will give you as much notice as possible regarding annual leave or absence. If your counsellor falls ill on the day of your session, Bucks Mind will make every effort to contact you before the session time.


  • The content of the sessions will remain confidential. However, should you disclose that you are at serious risk of harm to yourself, to others, or that you know of anybody who is at serious risk of harm, or any safeguarding concerns (current or historic) or specific illegal activities, the counsellor will share this information with Bucks Mind Safeguarding Lead and follow Bucks Mind Safeguarding procedures. The counsellor will always endeavour to inform the young person if a disclosure needs to be shared unless it is deemed unsafe to do so.
  • All counsellors are required to have supervision and will need to discuss their work with a supervisor. All details are anonymised, and your counsellor will not disclose any information that would enable you to be identified.

GDPR (General Data Protection Regulation)

  • If we have an agreement or contract with you to provide a specific service which is counselling, the lawful basis on which we collect, and process data is ‘contract’. This means that we are processing data to fulfil – or determine if we can fulfil our obligations to you under the agreement.
  • We will only use personal and specific category data to provide and evaluate the services we provide. We will not pass on the data we have about you to anyone else without your express permission except in exceptional circumstances, the lawful basis of which is ‘vital interests’. Examples of these circumstances might include information that suggests you might be a danger to yourself or someone else, or information about a child at risk of harm or neglect.
  • Buckinghamshire’s Mind full privacy notice can be found on our website
  • If a client hopes to use counselling in support of legal action or a compensation claim, please be aware that Buckinghamshire Mind is not able to provide any form of diagnosis or feedback that speculates on a person’s behaviour or future behaviour.

Computer Privacy (for online sessions)

  • Your online counselling sessions will be conducted live via an internet link. When working online it is important to maintain security through reasonable measures. It is your responsibility to secure your computer against unauthorised viewing by third parties. Bucks Mind uses an encrypted communication link which offers a high level of security.

Your personal welfare and safety

  • Please ensure you have a safe, confidential, and quiet space in which to have your sessions (if working online) and that you will not be disturbed while in session. Sessions cannot take place if you are under the influence of drugs, alcohol, or non-prescription drugs.
  • If you live with a medical condition that may require emergency support e.g., allergy to insect bites, food allergy, epilepsy, diabetes, you will need to inform your counsellor as a precaution; if you become incapacitated during the session due to a medical emergency, your counsellor will need to contact the emergency service on your behalf.
  • I understand that information relating to support provided as part of the counselling service by Bucks Mind will be recorded on Bucks Mind data management system (CRM).
  • By signing above, I agree to the terms set out above.
Privacy Statement

We need to keep some information about you to give you the right support at Bucks Mind. 

When you start a service we need to know things like your name, date of birth, address and phone number so we can get to know you, work with you in the best way and contact you if necessary. We also collect information about your ethnicity, religion and gender which we use to check we are reaching all groups of people in the community.  

Other information like your GP or mental health worker and your current health and wellbeing are important so we understand how you are, how we can best support you and who to contact if we are worried about you. 

When we complete a support plan with you we may ask you what you like doing and what your goals are so we can help you achieve them. Some people’s stories and photos make lovely case studies and we may ask your permission to share these to show how our services can help people. 

We are a confidential service and want you to feel safe and respected. We will always ask you before we share information about you and we will tell you what we are doing and why. Information about you is private which is why we check with you first. If you were to become very unwell or were unable to make your own decisions (we call that lacking capacity) then we may share information if we felt you or someone else may be in danger. This may be with a GP, family member or someone else who supports you to make sure you are safe. 

We only keep information if we really need it and we look after it carefully. 

If you would like to read our full Privacy Policy, please click on the button below.

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